It's been a long long wait since it was announced, the tobacco industry lobbied hard against it, managed to get the warning size reduced but the MoH has thankfully prevailed. Graphic health warnings on cigarette packs become a realityMonday, May 31, 2010 Shahina Maqbool Islamabad In spite of the tobacco industrys untiring efforts to stall the process for incorporation of pictorial health warnings on cigarette packs and outers, and to somehow have the momentous decision reversed, the Ministry of Health has elevated Pakistans international profile by formally launching picture-based health warnings with effect from today (May 30). The warnings, which were announced in May 2009 by the then minister for health, Mir Aijaz Hussain Jakhrani, will be launched by Minister for Health Makhdoom Shahabuddin at a ceremony arranged to observe World No Tobacco Day. Ours is the 21st country in the world to be implementing graphic health warnings. Pakistan took a giant leap forward last year by announcing historic measures for tobacco control, the introduction of picture-based health warnings being one of them. Even though these warnings were initially planned for implementation with effect from January 2010 and were delayed several times under pressure from various quarters, notably the tobacco industry, their implementation in Pakistan is doubtlessly a huge achievement that deserves to be acknowledged and appreciated. Picture-based warnings appear in more than a dozen countries. The number of countries implementing picture warnings has risen from one in 2005 to 23 in 2009. Some of the Eastern Mediterranean Region countries using picture warnings are Jordan (2005); Egypt (2008); Iran (2009) and Djibouti (2009). The Country Office of the World Health Organisation (WHO) in Pakistan has been encouraging the government to adopt picture-based health warnings that meet the criteria for maximal effectiveness. The subject was first raised during a presentation made in 2008, and then at the first meeting of the Technical Advisory Group in the beginning of 2008. After that, there was no looking back as the need for picture-based warnings was highlighted at every forum, with trainings being arranged for TAG members and the Ministry of Health. The media too played a lead role in having these warnings implemented in Pakistan. The WHO particularly approves of tobacco health warnings that contain both pictures as well as text and urges countries to have a rotated series of warnings appearing at the same time, rather than just one. Multiple warnings provide more information to the consumer, increase overall impact, and reduce the wear-out effect. The first picture-based warning to appear on cigarette packs in Pakistan shows the effects of tobacco use on a patient suffering from mouth cancer, and will be replaced with a new one after a year. Picture-based health warnings are particularly significant for countries like Pakistan, which are beset with poor literacy rate and inadequacy of resources for public health education. Such warnings are the most cost-effective communication medium available to convince people to quit. At present, a majority of the countrys illiterate population cannot decipher text-based warnings, and as such, remains oblivious of the deleterious consequences of tobacco use. Moreover, it is interesting to note that while picture-based warnings are determined by the Ministry of Health, the cost of the intervention is borne by tobacco companies. Such warnings are synonymous to mini-billboards that work 24/7. Coming to the size of the health warning, we have examples of countries like Australia, New Zealand and Cook Islands, where the average front-back size of the warning covers 60 per cent of the pack; followed by Belgium and Switzerland (56%), Finland and Kyrgyzstan (52%) and 18 other countries (50%). In Pakistan, these warnings will cover 40% of the front and back of cigarette packs (30% being pictorial and 10% textual). The WHO Framework Convention on Tobacco Control (FCTC) recommends that these warnings should cover 50% or more of the principal display area but shall be no less than 30% of the principal display area. The key objectives governing the introduction of health warnings are to inform consumers of the harmful effects of tobacco and to reduce consumption. Studies show that smokers are not aware of or underestimate the health effects of tobacco use. In 1999, before the introduction of picture-based warnings in Canada, only one-third of smokers could recall that heart attacks and emphysema are caused by smoking. In Cuba in 1999, 17% of doctors and 20% of nurses who smoked believed that smoking caused more benefits than harm. In the US in 1995, only 39% of heavy smokers believed they had a higher risk of heart attack and only 49% believed they had a higher risk of cancer. Real-world evidence from Canada and Singapore substantiates the usefulness of picture-based warnings to influence its consumers to quit. In Canada, 58% of the smokers thought more about the health effects of smoking as a result of the warnings; 44% said the warnings had increased their motivation to quit; and 27% of the smokers smoked less inside of their home as a result of the warnings. In Singapore, 71% of the smokers said they knew more about the health effects of smoking as a result of the warnings; 28% said they smoked fewer cigarettes as a result of the warnings; and 14% said they avoided smoking in front of children as a result of the warnings. With picture-based warnings finally becoming a reality in Pakistan, it would be useful for the WHO to support, in due course of time, similar studies to measure the impact of these warnings on smokers and non-smokers alike in this country.