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Will shock tactics work?

The gruesome results of smoking are to appear as graphic images on cigarette packets. Helen Mooney reports.

It's official: smoking kills and smokers on average die younger than non-smokers – the evidence is irrefutable. Smoking is the UK’s single biggest preventable killer and causes the premature death of more than 87,000 people each year in England alone.

The government last week took a further step to encourage people to kick the habit. From the start of this month, tobacco manufacturers in the UK have to add one of a selection of 15 graphic picture warnings on cigarette packets to highlight the results of smoking on the body.

The new warnings, which will have to cover 40% of the back of a cigarette pack, include pictures of rotting teeth and lungs, throat cancer and a ‘flaccid’ cigarette.

By October 2009, all cigarette packs sold in the UK will have to feature the warnings by law and, from October 2010, picture warnings will start appearing on all other tobacco products.

Chief medical officer for England Sir Liam Donaldson said he was clear about the benefits of using these images. ‘They show smokers the grim reality of the effects smoking can have on their health,’ he said in a statement officially launching the new designs.

‘This will help to maintain the momentum of the increasing number of people who have given up smoking following England going smoke free in 2007.’

Sir Liam said that the designs would put a stronger emphasis on the harsh health realities of continuing to smoke, going further than the written warnings already on cigarette packets.

In the same statement, health secretary Alan Johnson denied claims that smokers were being ‘demonised’ by the move.

The graphic images were necessary, he said, because of the diminishing impact of written warnings on tobacco products.

‘We do think it will help the number of people who want to give up smoking – the vast majority of smokers want to give up – and this will give them an extra push,’ he said.

The UK has taken a bold step in introducing this legislation and will become the first country in the EU to publish the pictures on all tobacco products.

It joins nine other countries – Australia, Brazil, Canada, India, New Zealand, Singapore, Venezuela, Thailand and Uruguay.

Canada was the first country to put visual warnings on cigarettes in the year 2000 and more than 70% of adults and nearly 90% of young people in the country say they believe the images are effective. A poll of Canadian smokers also found that more than half said they smoked less around other people as a result of the graphic images and 15% said they had been deterred from having a cigarette after seeing one of the images.

The RCN’s tobacco policy adviser, Jennifer Percival, welcomed the new graphic cigarette packages.

‘This can leave smokers in no doubt that smoking is a dangerous habit and it is another nail in the coffin for tobacco manufacturers who have to bear the cost of printing the images on cigarette packs,’ she said.

Ms Percival suggests that nurses use the new images as a starting point for having a conversation with their patients who continue to smoke.

‘Nurses can ask their patients whether they have seen the images and whether they think that anything like that could happen to them – don’t tell your patients off but you can use the pictures to plant the seed that gets them to think about the effects of smoking and then offer them the extra advice and help on offer to encourage them to quit,’ she said.

The charity Cancer Research UK has estimated that the images could help an additional 10,000 smokers in England quit, equivalent to one in 1,000.

Robert West, professor of health psychology and director of tobacco studies at Cancer Research UK, said that putting the images on packets was also an ethical consideration.

‘Smokers need to be reminded about the harm of smoking in a more salient way. They have a right to have the information more readily available – it is too easy to turn a blind eye. I think the tobacco companies ethically have a responsibility to do this,’ he said.

Professor West noted that the Department of Health and the British Heart Foundation’s previous television advertising campaign, which featured fat dripping out of cigarettes to highlight the effect of smoking in clogging arteries, had a marked effect in prompting people to seek out smoking cessation services.

‘The main emotion prompted by those adverts was disgust and I think that is stronger than fear. I hope these images have the same effect and that they begin to be harmonised with other quit smoking advertising campaigns,’ he said.

Bob Smith, clinical nurse specialist at the Maudsley smoker’s clinic in South London, agreed. ‘I think this will make a difference.

The TV adverts with the dripping fat prompted more people to visit the clinic I work in – we had a sharp increase. That was evidence that graphics can work,’ he said.

However, Mr Smith added that he thought that web addresses and the NHS Direct number should be run with the pictures so people knew where they could access support and advice on giving up smoking.

But Dawn Hull, smoking cessation nurse at County Durham PCT, is more sceptical.

‘There might be the odd one or two smokers who give up as a result of the pictures but, on the whole, I think they will be ignored – there is the mentality of “it will never happen to me”,’ she said.

Ms Hull said the images had to be used as part of a combined approach to smoking cessation. ‘This is just another piece of
the jigsaw. We still need to concentrate on providing drop-in clinics and one-to-one counselling sessions and a whole range of measures to get people to quit,’ she added.

It is likely that the graphics will make some impact in the short term and Cancer Research UK intends to map whether more people access smoking cessation clinics as a result.

‘Every nurse has seen somebody die prematurely because of smoking,’ said Ms Percival. ‘These pictures are real and this brings the whole reality of smoking one step closer.’

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