With the unveiling of nine graphic images that will adorn every cigarette pack sold in the US starting in fall of 2012, government officials and outside experts predict there will be an initial wave of smokers seeking help in quitting. But they caution that regulators will have to refresh—and possibly dial up—their message so that consumers don’t grow complacent about the omnipresent warnings.

The graphic labels released last week are “an important and powerful tool” in the fight to reduce tobacco-related disease and death, said Food and Drug Administration (FDA) Commissioner Margaret Hamburg. She estimated the new campaign could induce as many as 213,000 of the nation’s 46 million cigarette smokers to quit in just the first year of the campaign. The American Lung Association warned local quit lines to brace for a deluge of phone calls.

Hamburg and other officials also stressed that the FDA will continue to study the effect the images have on the public, and will likely update the images yearly in an effort to keep them and their message fresh in consumers’ minds. Outside experts said the US government will have to vary its messages to avoid what psychologists call “wear out.”

The nine images chosen by the FDA—the first update to cigarette-package warnings in a quarter century—are stark and often disturbing, and each is accompanied by simple text informing cigarette buyers of the known consequences of their habit. One of the nine appears to depict a recently autopsied cadaver and states simply, “Smoking can kill you.”

Another, set against the warning, “Cigarettes are addictive,” shows a man blowing cigarette smoke out of the tracheostomy hole in his throat.

Other warnings make a clear appeal to smokers’ concern for others, an approach that research has found highly effective in getting smokers to try quitting. In one, a photo of a distraught woman bears the warning, “Tobacco smoke causes fatal lung disease in nonsmokers”; in another, a toddler clutched to the chest of an adult gazes anxiously at a nearby swirl of smoke, accompanied by the message, “Tobacco smoke can harm your children.”

Only one of the images conveys hope and encouragement to the dwindling number of Americans who cling to their smoking habit despite growing social isolation and, in almost four-in-five smokers, a strong desire to quit. In it, a robust, 30-something man with a sharp-looking goatee and a determined stare pulls open his shirt to reveal a T-shirt that declares, “I Quit.” The text reads, “Quitting smoking now greatly reduces serious risks to your health.”

Unimpressed

The new initiative is the most dramatic of the steps taken by the FDA since the 2009 Family Smoking Prevention and Tobacco Control Act gave the agency expanded regulatory powers over tobacco. It is also the first time in 25 years that the health warnings on the packaging of tobacco products has been updated beyond the bland statement, in small type, that the Surgeon General of the United States has determined cigarette smoking to be harmful to human health.

The new warnings didn’t impress everyone.

“They’re obnoxious,” said Long Beach, California, resident Bob Kohl, a 60-year-old smoker of 43 years who was diagnosed two years ago with emphysema and has quit three times. “They are insulting. They are very specifically condescending, which irritates me. It’s nothing I haven’t seen before, and it’s going to be meaningless to the kids, because their attitude is worse than mine.”

In requiring the graphic warnings, the United States joins some 40 other countries around the world that already require cigarette packaging to carry prominent—and often very grim—warnings on the dangers of smoking. Canada and Europe pioneered the practice, and several developing countries, including Mauritius, Uruguay, Thailand, Malaysia and India, have also preceded the United States in requiring such graphic antismoking messages.

Starting September 22, 2012, the images and related text will cover the top half of each cigarette package sold in the United States, making them “new minibillboards for prevention,” said Dr. Howard Koh, assistant secretary for health at the Department of Health and Human Services.

The warnings, added William Corr, deputy secretary of HHS, “will forever change the look” of the 15 billion packs of cigarettes purchased by Americans annually.

The truth

The mandated package coverings “tell the truth,” Corr said, contrasting them with messages crafted by the tobacco industry, which spends $12.5 billion annually to advertise its wares.

The images were culled from a group of 36 candidates circulated for public comment starting last June by the FDA. In choosing the nine labels, the agency ruled out a number of far more disturbing images, including an unsparing photograph of a bald lung cancer victim hollowed out by her disease.

But as the American public grows inured to the effects of the new images, the FDA might well turn to images it may have passed over as too grisly and discouraging to American smokers, experts said. As it escalates the shock value of the images it presents to smokers, the FDA must thread a careful path between simply sticking to the facts and presenting images and warnings in ways that are attention-grabbing enough to break through smokers’ resistance and discouragement, said Geoffrey Fong, lead researcher of the International Tobacco Control Policy Evaluation Project at the University of Waterloo in Canada.

“It’s a really good start,” Fong said. “But we also need to recognize where people in the United States are right now, which is no exposure to these kinds of images.”

Fong, who has studied the effectiveness of Canada’s 2001 introduction of graphic warning labels, said while those warnings had a powerful impact on smokers’ intentions to quit in the first two to three years, their sway with consumers declined markedly—by 30 percent to 60 percent—between 2003 and 2009, when Canada stuck with the same warnings.

The messages “don’t have to be more intense, they could just be different,” Fong added. “With the harms of smoking, you have a lot to choose from; you’re not going to be running out of ideas.”

(AP photo)