ARCHIVED - A Proposal for New Health-related Information on Tobacco Product Labels
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Building on Success
A Consultation Paper
- Executive Summary
- 1.0 Introduction
- 2.0 Background and Context
- 2.1 Tobacco Use in Canada
- 2.2 Federal Tobacco Control Strategy
- 2.3 The International Situation
- 2.4 A Look Back - Tobacco Labelling in Canada
- 3.0 Summary of the Research
- 4.0 Proposed Changes to Labelling Requirements
- 5.0 Providing Feedback
Health Canada is proposing changes to the labelling requirements for tobacco products. The goal of labelling is to increase awareness of the health hazards and health effects associated with tobacco use. The current approach and supporting regulations have been in place since 2000 and target tobacco users with messages that are noticeable, informative and credible. The labelling requirements focus messages in three areas: health warnings, health information messages and toxic emissions/constituents statements.
The research shows that the current health warnings are working well...
Research and evaluation results clearly and strongly support the overall direction of tobacco labelling in Canada. In particular, results show that both smokers and non-smokers of all ages strongly support the graphic health warnings found on the principal display of tobacco product packages. The warnings are considered noticeable, serve as a major (in some cases, the major) source of information on the health effects of tobacco use, and are seen as both credible and informative.
...but could be improved for many Canadians
Recent research shows that some of the health warnings are not as effective at reaching adults with low levels of literacy. In essence, some of the images and written messages could be made simpler to ensure they are fully understood by all who read them.
The toxic emissions/constituents statements are unclear to some smokers...
Many people find the toxic emissions statement confusing; in particular, the ranges listed for each emission are not always well understood and few people can recall all six substances listed (tar, nicotine, carbon monoxide, formaldehyde, hydrogen cyanide and benzene).
...and smokers often overlook the health information messages and tips about quitting
Not everyone is aware of the health information and tips about quitting that are included on the back panel of the slide and on the upper-slide flap on slide and shell packaging or as an insert in flip-top packaging.
Proposals for Change
Health Canada is proposing to make changes to all three components. In brief, the proposals are to:
- Create a series of health warnings that include a variety of approaches and messages tailored to different needs. These warnings would be rotated every two years. In particular, the health warnings could include:
- Some messages tailored to adults with low literacy skills and to other audiences (potential quitters, hard-core smokers)
- Some mixed messaging including both a health warning and a related benefit associated with quitting
- Some messages about toxic emissions/constituents including, for example, the health effects of one emission or constituent.
- Develop new health information messages that are clear, positive and action-oriented in nature. These new messages would be made more noticeable by:
- Moving the health information message from the back panel of the slide-and-shell package to the upper slide flap
- Including other information of use to smokers (e.g., a "quitting" schedule with a clear message about quitting) on the back panel or on the leaflet.
- Replace the current toxic emissions/constituents statementwith a series of new statements that each focus on one single substance. These revised statements would be rotated every two years and would:
- Present clear information about the substance and its health effects, including information such as its range (for emissions) or level (for constituents)
- Be distributed equally amongst packages, in the same way as the current health warning messages.
Taken together, the changes proposed by Health Canada would build on the success of the current tobacco labelling requirements. The Department welcomes feedback and comments from the public and stakeholders and invites additional suggestions (see section 5.0 for more information).
Health Canada is proposing new provisions for the Tobacco Products Information Regulations under the authority of section 17 of the Tobacco Act. The Department's proposal, as set out in this consultation document, reflects the Government of Canada's commitment to inform Canadians of the serious health hazards of using tobacco. Interested parties and citizens are invited and encouraged to provide comment on this proposal. Your input could help shape the direction the government takes in this regard. See section 5.0 for information on how you can participate in this consultation.
Why change tobacco product labelling now?
The current product labelling requirements have been in place since 2000. They were developed to reach tobacco users with noticeable, informative and credible messages. Qualitative and quantitative research has shown that the current requirements for health warnings (one of the key components of product labelling) have achieved a good measure of success. Moreover, they now serve as a model for other countries.
That said, research also indicates that the health warnings are not equally effective at reaching all current and potential smokers. In particular, people with low literacy skills do not readily understand the health warnings and toxic emissions statements. In addition, the toxic emissions/constituents statements and the health information messages are not as noticeable or informative as intended.
How to make the most of this consultation document
This consultation document presents an overview of tobacco product labelling in Canada and other countries, a summary of Health Canada's research on the current messages and a set of proposed changes to tobacco product labelling. Specifically, section 4.0 outlines the types of changes Health Canada is considering making to:
- the graphic Health Warnings found on the principal display surfaces of most tobacco product packaging
- the Toxic Emissions Statements found on the sides of most smoked tobacco product packages and toxic constituent statements required on most smokeless tobacco products, and
- the Health Information Messages located on the back panel of the slide and on the upper-slide flap on shell type packaging or as leaflet in flip-top packaging.
The changes proposed in section 4.0 are based on the research presented in section 3.0 and are meant to better address the needs of a more varied audience and to ensure labelling continues to be noticeable, informative and credible. More information on independent research and research commissioned by Health Canada on the impact of the current tobacco labelling requirements can be found on the Tobacco Control Programme's website (www.gosmokefree.ca).
Although this consultation document focuses on the labelling of cigarette packages, changes will also be considered for the labelling of all tobacco products sold in Canada, including tobacco sticks, leaf tobacco, cigars, pipe tobacco, bidis, kreteks (also called clove cigarettes), water pipe tobacco (also called narguileh and shisha), and all types of smokeless tobacco intended to be sniffed, sucked or chewed.
2.0 Background and Context
2.1 Tobacco use in Canada
Over the past 40 years, Canada has made significant progress in reducing tobacco use. Indeed, the percentage of adults who smoke has dropped by half. Nevertheless, tobacco use remains the most serious preventable public health problem in this country with about 5 million Canadians still using tobacco. In 1998, the most recent year for which data is available, more than 45,000 Canadians died from diseases attributable to tobacco use. One thousand of these deaths resulted from exposure to second-hand smoke.
Canadians smoking rates keep going down
The most recent results (Wave 1, 2003) from the Canadian Tobacco Use Monitoring Survey (CTUMS) show that about 20% of the population aged 15 years and older are current smokers (16% are daily smokers). This percentage represents a slight decrease from rates for the first half of 2002 (21%).
Smoking rates among youth 15-19 years old are even lower (18%) with 11% reporting daily smoking and 7% reporting occasional smoking. These numbers represent a continuation of the downward trend seen in recent years and a slight decrease from 22% in 2002.
The prevalence of smoking among young adults aged 20-24 years old is 30% (22% daily, 8% occasional), a slight decrease from the 2002 rate (31%).
Canadians smoke fewer cigarettes
Not only are fewer Canadians smoking, but they are also smoking fewer cigarettes on a daily basis. Since 1985, the number of cigarettes consumed by daily smokers has dropped from an average of 20.6 cigarettes to 15.7. Men continue to smoke more cigarettes per day than women (17.8 compared to 13.2 for women).
One quarter of Canadians have quit smoking
One quarter of Canadians aged 15 years and older report being former smokers. Health concerns were named as one of the most common reasons for quitting.
2.2 Federal Tobacco Control Strategy
The Government of Canada is convinced that the most effective way to prevent and reduce tobacco use is to address the problem at all levels of society. To this end, the Government's tobacco control efforts have tackled tobacco use on several fronts, including:
- Requiring large, pictorial health warnings to be printed on tobacco packaging, to draw attention to the health consequences of using tobacco products
- Restricting the promotion of tobacco products and banning all sponsorship promotions
- Conducting mass media campaigns about cessation and second-hand smoke and distributing supporting materials
At the community level, great strides have been made to reduce the impact of second-hand smoke. As of 2003, more than 300 communities had smoke-free by-laws.
Health Canada's Tobacco Control Programme has been given a challenging 10-year mandate under the Federal Tobacco Control Strategy. The 10-year objectives are to:
- Reduce smoking prevalence from 25 per cent (level in 1999) to 20 per cent
- Decrease the number of cigarettes sold by 30 per cent
- Increase retailer compliance with tobacco-sales-to-youth laws from 69 to 80 per cent
- Reduce the number of people exposed to second-hand smoke in enclosed public spaces
- Explore how to mandate changes to tobacco products in order to reduce health hazards
2.3 The International Situation
The World Health Organization has identified more than 100 countries that have mandated some sort of health warnings related to tobacco products. Notable developments in recent years are listed below.
- Australia is in the final stages of introducing labelling regulations similar to Canada's. The government of Australia is currently seeking feedback on proposed regulations that would see cigarette packages include large graphic health warnings and information about the effects of smoking on health. Some of the proposed options are for health warnings to (1) occupy 50% of the front and the back, or (2) 30% of the front and 90% of the back of cigarette packages, and for the 14 warnings to be rotated, seven at a time, every two years.
- Brazil has developed new graphic health warnings, to be displayed on cigarette packages by August 2004. Brazil already requires that health warnings fully cover one of the two principal display surfaces. The new requirements include the mandatory display of graphic images with stronger messaging and a prohibition on associating the product's brand name with the disclosure of the product's nicotine, tar and carbon monoxide levels.
- The European Union's 2001 Directive on Tobacco Packaging has been adopted. The 15 EU member states require large text-only health warnings (30% of the front of the packet, 40% of the back, depending on the state's number of national languages) with a border to be displayed on packaging. Pictures may soon be added to the health warning requirements. The yields of tar, nicotine and carbon monoxide must be displayed on larger surfaces on the sides of the packets.
Canada, along with more than 150 other member states of the World Health Assembly, contributed to the development of the international Framework Convention on Tobacco Control (FCTC). Canada signed the FCTC in July 2003. The FCTC must be ratified by 40 countries in order to come into force.
While Canada's current tobacco control initiatives already incorporate the vast majority of the FCTC requirements, some minor additions must be made to Canada's regulations. With respect to labelling, health warnings would have to occupy no less than 30% of the principal display surfaces of packages of all types of tobacco products (article 11 of the FCTC).
2.4 A Look Back - Tobacco Labelling in Canada
Prior to 1988, some tobacco product manufacturers followed a voluntary labelling code. The first Canadian law to mandate tobacco product labelling was the Tobacco Products Control Act (TPCA), passed by Parliament in 1988. In 1995, the Supreme Court of Canada found the TPCA's labelling provisions inoperative, stating that tobacco manufacturers should have the option of attributing the warnings to their author.
In 1997, Parliament passed the Tobacco Act. The Tobacco Products Information Regulations, adopted under the authority of the Act in 2000, represented a major departure from past labelling approaches. Not only did the new regulations require graphic health warnings to be displayed, they also mandated the inclusion of health messages containing information to help people quit smoking and expanded the requirements for presenting toxic emission/constituent levels.
3.0 Summary of the Research
3.1 Effectiveness of Current Labelling - Cigarette Packages
Health warnings are noticeable, credible and informative to smokers ...
Canadians have indicated widespread support for the health warnings on cigarette packages. Most of them see the warnings as an accurate and important source of information. Moreover, most youth and adult smokers say the messages make smoking less attractive (Environics 2004a, Environics 2004b). Almost all Canadians have seen the current health warnings even though fewer than one-half of smokers say they read them every day. Eighteen per cent of adult smokers say they never look at or read the warnings, while only 7% of youth smokers aged 12 to 18 years say they never look at the messages.
Out of sight, out of mind
Some smokers say they avoid looking at or thinking about health warning labels by keeping the pack out of sight (13% of adult smokers; 21% of youth smokers) (Environics 2004a, 2004b).
Smokers use the health warnings as a source of information about the impact of smoking on health and as a tool to increase their desire to quit smoking (Environics 2004a, Environics 2004b). In fact:
- More than seven in ten adult smokers and almost nine in ten youth smokers say health warnings are effective at informing them about health effects
- More than half of adults and youth say the messages compel them to smoke less around other people and increase their desire to quit smoking
- Slightly smaller proportions say the health warnings are effective in getting them to try quitting or to smoke less.
A 2001 study suggests that smokers who read, think about and discuss the health warnings are more likely to quit, attempt to quit or to reduce their smoking (Hammond, Fong, McDonald, Cameron, Brown, 2003).
Another study determined that health warnings would be more effective if their content was more positive and if the current negative messaging about the health impacts of smoking was combined with positive messages about the benefits of quitting smoking. The authors also stressed the importance of including messages that encourage discussion about smoking. They argued that messages that encourage people to recognize that their behaviour differs from their beliefs play a role in changing behaviour. They also discussed the benefits of tailoring messages to different groups (Strahan, White, Fong, Fabrigar, Zanna, Cameron, 2002).
Teen smokers rely on health warnings and health information messages...
For youth smokers, cigarette packaging is a major source of information about the health effects of smoking. Fifty per cent of youth smokers say they have recently seen or heard information about the health effects of smoking on cigarette packaging, compared to 55% for television and 36% for school/university (Environics 2004b). In addition, youth smokers look at the packaging more often than adult smokers: 80% say they look at or read health warnings several times a day, once per day or once every two-three days or about once a week, compared to 66% of adult smokers (Environics 2004a, 2004b).
Health information messages - accurate and useful
More than one-half of adult smokers and more than three-quarters of youth smokers see the information on the health information messages on the back panel of the package slide or leaflet as accurate. Almost as many say the information is useful to them (Environics, 2004a, 2004b).
Youth smokers are also more frequent readers of health information messages on the back panel of cigarette slide-and-shell packs; 31% of youth smokers say they read the information once a week or more, compared to 20% of adult smokers. When asked if they recall seeing anything on the back of the slide, 31% of youth smokers mentioned tips to stop smoking, compared to 11% of adult smokers (Environics 2004a, 2004b).
These results, combined with others summarized here, suggest that labelling may be more effective for the youth audience than previously thought (Health Canada 2003b).
Toxic emissions statements could be improved...
Smokers clearly support the inclusion of toxic emissions information on packaging. One-half of adult smokers and six in ten youth smokers say they look at or read the toxic emissions statements on the side of cigarette packages (Environics 2004a, 2004b).
Smokers want direct, easy-to-understand information about toxic emissions ...
When shown a series of possible statements, smokers in a qualitative study were most supportive of texts that were short, clear and simple and that presented only one substance with information on the impact that substance has on health (Environics 2003b).
While at least six in ten smokers recall that nicotine and tar are listed as toxic emissions on cigarette packaging, fewer than three in ten recall any of the other four substances: carbon monoxide, formaldehyde, hydrogen cyanide and benzene (Environics 2004a, 2004b).
Studies indicate that adult smokers are somewhat aware that nicotine (43%) and tar (35%) can cause diseases or health problems, and only a very small percentage mention carbon monoxide, formaldehyde, benzene or hydrogen cyanide (Environics, 2004a). Nevertheless, some smokers are encouraged to try to quit by this information (37% of adult smokers and 45% of youth smokers) and others are encouraged to smoke less (31% of adult smokers and 40% of youth smokers) (Environics 2004a, 2004b).
The current labelling approach is not as effective reaching adults with low literacy skills...
The 1994 International Adult Literacy Survey (IALS) identified and measured three types of literacy: prose literacy (the ability to understand and use information from texts such as news stories or fiction), document literacy (the ability to find and use information from documents such as maps or tables), and quantitative literacy (the ability to make calculations with numbers imbedded in text, as in balancing a chequebook).
Smoking and education...
Canadians who report lower socio-economic status and education levels are more likely to smoke. Only about one in eight (14%) university graduates smoke, compared to almost one in three (30%) adults who did not finish high school (CTUMS, 2000).
IALS measured proficiency at five different levels within each literacy type. Twenty two percent (22%) of Canadians, ages 16 and older measured up in prose literacy, have difficulty reading and have few basic skills or strategies for decoding and working with text (level 1). As well, 26% of Canadian adults are identified as having limited skills; they read, but do not read well (level 2). Canadians at this level can only deal with material that is simple and clearly laid out (HRDC website [n.d.]).
Health Canada studies indicate that the current tobacco labelling approach is not appropriate for most Canadians with low literacy skills. For example, while people with low literacy skills know that smoking is bad for them, many of the words, images and concepts used in the current health warnings are too difficult or abstract to communicate this message effectively to this group; rather, they are more ready to reject the messages than make an effort to understand them (Créatec, 2003a).
Health information messages are not sufficiently noticed or read by adult smokers...
Canadians (including smokers) are not very aware of the health information messages located either on the back panel of the slide portion of cigarette slide-and-shell packs or on the stand-alone leaflet placed in other types of cigarette packages. In fact, not enough Canadians can recall what is on the back of the slide portion or on the leaflet (Environics 2004b).
When asked, top-of-mind, if they can recall or describe anything they saw or read on the back of the slide portion of a cigarette package (without looking at the package), almost six in ten adult smokers say there is nothing (1%), offer no opinion (37%) or say they have not seen the slide portion (19%)(Environics 2004a).
3.2 Health Warnings on Smokeless Tobacco, Cigars and Pipe Tobacco
While research on the effectiveness of health warnings and toxic emissions statements has focused on cigarette packaging, at least one national qualitative study provides useful insight into perceptions and opinions of users of other tobacco products (Créatec, 2003b).
What do they think?
Many people who smoke cigars or pipes or (regardless of whether or not they also smoke cigarettes) see these products as less addictive and less harmful than cigarettes.
Smokeless tobacco users generally see their product as addictive but less harmful to themselves and others because the products are smokeless (Créatec, 2003b).
The study results suggest that even though users of these other products believe that there is enough (or too much) information available on the health effects of tobacco use, their understanding and recall of the health warnings on packaging could be improved.
The messages that appear to have the highest credibility include those related to second-hand smoke, mouth diseases and addiction. In summary, while users of cigars, pipe tobacco and smokeless tobacco products see health warnings on these products as important, the current slate of messages are not seen as informative.
3.3 Direction from the Research
Research findings strongly support the direction that Canada has taken in developing its current labelling approach. Findings highlight particular aspects that work well and others that could be improved. In particular:
- Adults with lower literacy skills could be reached more effectively. A large proportion of the general population and of the population of smokers is not being reached effectively by the current approach of information and graphic images. The images and written messages are too complex in their own right and, taken together, are too conceptually difficult to be understood in the intended way by this group.
- The toxic emissions statement could be improved to reach more groups of smokers. The current selection of substances is not well understood. Only two of the six substances listed are recalled by more than 50% of the readers.
- Messaging in the health warnings is not reaching all audiences, particularly adults with lower literacy skills, older smokers and hard-core smokers. A more varied approach - such as rotating health warnings with messages about the benefits of quitting and messages of encouragement for those contemplating quitting - may be more successful for reaching a broader audience.
- Health information messages(on the back panel of the slide and on the upper-slide flap on shell type packaging or as leaflet in flip-top packaging) are being noticed or read by few adult smokers.
4.0 Proposed Changes to Labelling Requirements
The following pages set out a series of proposals outlining the types of changes that Health Canada is considering making to health warnings, toxic emission/constituent statements and health information messages. The proposals, while presented mainly for cigarette packaging, would be adapted for all tobacco products currently sold in Canada, such as tobacco sticks, leaf tobacco, cigars, pipe tobacco, bidis, kreteks (also called clove cigarettes), water pipe tobacco (also called narguileh and shisha), and all types of smokeless tobacco intended to be sniffed, sucked or chewed.
Health Canada welcomes your comments on these proposals, as well as additional suggestions. A number of questions are included to you to assess the proposed changes and provide feedback.
4.1 Health Warnings
Create some messages tailored for varied audiences such as adults with low literacy skills, youth, hard-core smokers and people thinking about quitting smoking by:
- Creating messages of encouragement with information on the health benefits of quitting and tips on how to quit smoking
- Designing simple but informative messages about toxic emissions/constituents including, for example, the health effects of one of the toxic substances found in tobacco or in tobacco smoke
- Developing 48 warnings, displayed a number at a time, distributed equally among all packages, and changed every two years through rotation
- Combine health warnings with messages about the benefits of quitting, tips on how to quit or messages of encouragement for those thinking of quitting
- Continuing to require that messages occupy 50% of the principal display surfaces on most smoked products
- Expanding the requirements to 30% of the principal display surfaces for cigars, pipe tobacco, water pipe tobacco products and all types of smokeless tobacco products.
The current series of health warnings follows an approach that strongly shows the health hazards and effects of using tobacco. This approach has proven to be effective for providing information to many smokers. While the usefulness of the health warnings has not worn out, Canadians may be getting accustomed to the images displayed on tobacco packaging. The warnings could lose impact over time. The research makes a compelling case that messages could be tailored to better meet the needs of different segments of the population. In addition, having fewer messages displayed in the same period but changing the messages more often could improve recall.
- Consider and comment
- Do you see any benefits of developing messages aimed at particular audiences?
- What do you think about including some messages about the benefits of quitting or with tips on how to quit smoking?
- Can you suggest another way of presenting health warnings to smokers and potential smokers, or users of other tobacco products that would make them aware of the health impacts of tobacco use?
4.2 Health Information Messages
- Develop new health information messages for the back panel of the cigarette slide-and-shell pack, or for the leaflet, and for the upper slide flap of the package that:
- Are brief and clear, providing information that is more easily read and recalled than the current health information messages
- Are presented in larger type, so they are more easily read and recalled
- Are more positive and action-oriented in nature, telling people that they can quit and where to get information (namely, 1-800 number, Web site, health professional)
- Are more noticeable; for example, the health information message currently on the back panel could move to the upper slide flap
- Include other information of use to smokers (e.g., a "quitting" schedule with a clear message about quitting) on the back panel of the sliding pack or on the leaflet
Health Canada believes that information presented more clearly and simply, would be more noticeable and useful to smokers and potential smokers. Similarly, tobacco users with lower literacy skills would be better served by simpler, shorter health information messages. Information on where to go for help about quitting may be more useful than extensive quitting information.
- Consider and comment
- What are the benefits and/or strengths of the options presented above?
- What do you think about modifying the information presented and focusing on where to go for information about quitting?
- Do you have suggestions for other ways of improving the health information messages?
4.3 Toxic Emissions/Constituents Statement
- Proposal For smoked products, replace the current toxic emissions statement with a series of new statements that:
- Each focus on one of eight substances (e.g. nicotine, carbon monoxide, formaldehyde, acetone, hydrogen cyanide, benzene, toluene, benzo[a]pyrene) and present clear and concise information about that substance, its health effects and the range as currently displayed
- Are equally distributed amongst packages, in the same way as the current health warning messages
- For smokeless tobacco products intended to be either sniffed, sucked or chewed, require:
- A series of toxic constituent statements that each focus on one of three substances or classes of substance (nicotine, lead, nitrosamines) that present clear and concise information about the substance and its health effects, and the amount present in the product as currently displayed
- A statement about the product's carbohydrate contents, to better inform users about the high sugar content of some smokeless tobacco products.
- Rationale Users of this information have asked that the toxic emissions statement be more direct, clearer and easy-to-understand. The proposed changes are intended to address this request by ensuring that the toxic emissions statement on packaging is noticeable, informative and credible to a much larger segment of tobacco users.
- Consider and comment
- What are the benefits of the proposed changes?
- The proposal would eliminate the need to list all six toxic emissions and their ranges on every package. Do you have any concerns with eliminating the list?
- Can you suggest other ways for presenting toxic emissions/constituents information on packaging that would be noticeable and useful to tobacco users?
4.4. Other proposals, advice and comments
In addition to comments and feedback on the specific proposals outlined here, we encourage groups and individuals to provide other comments and suggestions that would enable Health Canada (within its mandate and under the authority of the Tobacco Act) to provide labelling that is noticeable, informative and credible.
In particular, we are interested in feedback that would help identify:
1. Missing information... Is there anything not included in our proposals that would help make the labelling more noticeable, informative and credible?
2. Additional proposals or considerations... We are open to ideas that would help smokers and potential smokers understand the health hazards associated with tobacco use and see that quitting is both possible and has health benefits.
3. General support for or disagreement with Health Canada's proposals... Even if you don't have other suggestions or ideas, we'd like to know if you generally support our approach to changing tobacco labelling. Let us know what you think.
5.0 Providing Feedback
Health Canada is committed to building on the success of the current labelling requirements. Health Canada encourages all interested organizations and individuals to consider the proposals presented here, to address the broad questions posed and to provide other feedback and information as we finalize the proposed changes to the Tobacco Products Information Regulations.
How and When to Submit Feedback
We encourage you to submit your feedback by mail, by fax or by responding electronically.
Comments and suggestions should be sent by November 5, 2004 to:
Ms. Christine Belle-Isle
Acting Manager, Regulations Division
Tobacco Control Programme
123 Slater Street
Ottawa, Ontario K1A 0K9
Fax: (613) 941-1551
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