ABSTRACT

Objectives.

To assess the adoption of tobacco packaging and labeling policies based on the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC)’s Article 11 guidelines, in the WHO Region of the Americas (AMRO).

Methods.

We reviewed tobacco control laws in AMRO from the Campaign for Tobacco-Free Kids’ Tobacco Control Laws database. We analyzed four sub-policy areas for smoked and smokeless tobacco products: 1) health warning labels (HWLs), 2) constituents and emissions (C&Es), 3) misleading tobacco packaging and labeling, and 4) standardized “plain” packaging.

Results.

Of 35 countries in AMRO, 31 have tobacco packaging and labeling laws. Twenty-six countries require pictorial HWLs, 24 require warnings printed on at least 50% of the front and back of the packs, and 24 rotate a single or multiple (from 2 to 16) warnings within a specified period (from 5 up to 24 months). Only 21 countries require descriptive messages on toxic C&Es information. Twenty-seven countries ban brand descriptors with references to implied harm reduction (e.g., “light”), 24 ban figures, colors, and other signs, but only 13 prohibit emission yields printed on the packs. Only Canada and Uruguay have adopted standardized tobacco packaging while Uruguay also requires a single presentation (one brand variant) per brand family.

Conclusion.

Many countries in AMRO have made good progress in adopting multiple, rotating, large pictorial HWLs and banning misleading brand descriptors. However, there needs to be greater attention on other tobacco packaging and labeling provisions with a focus on implementing standardized tobacco packaging.

Keywords
Tobacco-derived products labeling; tobacco-derived products packing; government regulation; health communication; Americas

RESUMEN

Objetivos.

Evaluar la adopción de las políticas de empaquetado y etiquetado de los productos de tabaco basadas en las Directrices del Artículo 11 del Convenio Marco para el Control del Tabaco (CMCT) de la Organización Mundial de la Salud (OMS) en la Región de las Américas de la OMS.

Métodos.

Se examinaron las leyes de control del tabaco en la Región de las Américas de la base de datos de legislación para el control del tabaco de la organización Campaign for Tobacco-Free Kids. Se analizaron cuatro subáreas de políticas sobre los productos de tabaco para fumar y sin humo: 1) etiquetas de advertencia sanitaria; 2) componentes y emisiones; 3) empaquetado y etiquetado engañoso del tabaco, y 4) empaquetado "neutro" estandarizado.

Resultados.

De los 35 países de la Región, 31 disponen de leyes de empaquetado y etiquetado de los productos de tabaco. Veintiséis países requieren etiquetas de advertencia sanitaria con imágenes, 24 requieren advertencias impresas en al menos 50% de la parte frontal y posterior de los paquetes, y en 24 se rotan una o varias advertencias (entre 2 y 16) en un período específico (entre 5 y 24 meses). Solo 21 países requieren mensajes descriptivos sobre componentes y emisiones tóxicos. Veintisiete países prohíben los descriptores de marca con referencias a una supuesta reducción de daños (por ejemplo, "suaves"), 24 prohíben imágenes, colores y otros símbolos, aunque solo 13 prohíben que las cifras de emisiones figuren en los paquetes. Únicamente Canadá y Uruguay han adoptado un empaquetado estandarizado de los productos de tabaco, si bien en Uruguay también es obligatoria una presentación única (variante de marca) por familia de marca.

Conclusión.

Muchos países de la Región han logrado avances en la adopción de diferentes etiquetas rotativas de advertencia sanitaria con imágenes de gran tamaño y en la prohibición de descriptores de marca engañosos. Sin embargo, es necesario prestar mayor atención a otras disposiciones sobre el empaquetado y el etiquetado de los productos de tabaco destinadas a la aplicación de un empaquetado estandarizado de estos productos.

Palabras clave
Etiquetado de productos derivados del tabaco; envasado de productos derivados del tabaco; regulación gubernamental; comunicación en salud; Américas

RESUMO

Objetivos.

Avaliar a adoção de políticas de embalagem e etiquetagem de produtos de tabaco com base nas diretrizes do Artigo 11 da Convenção-Quadro para o Controle do Tabaco (FCTC) da Organização Mundial da Saúde (OMS), na Região das Américas da OMS.

Métodos.

As leis de controle do tabaco na AMR foram examinadas com base no banco de dados das Leis de Controle do Tabaco da Campanha para Crianças Livres do Tabaco. Foram analisadas quatro subáreas de política para produtos de tabaco queimados/combustíveis e não geradores de fumaça: 1) advertências sanitárias, 2) componentes e emissões (C&E), 3) embalagem e etiquetagem enganosa de produtos de tabaco e 4) embalagem padronizada.

Resultados.

Dos 35 países da AMR, 31 têm leis sobre a embalagem e etiquetagem de produtos de tabaco. Vinte e seis países exigem imagens de advertência, 24 exigem advertências impressas que ocupem pelo menos 50% da frente (face anterior) e do verso (face posterior) das embalagens e 24 realizam rodízio de uma ou várias (de 2 a 16) advertências dentro de um período especificado (de 5 a 24 meses). Apenas 21 países exigem mensagens descritivas sobre C&E tóxicos. Vinte e sete países proíbem os descritores que levem a uma falsa impressão de redução de danos (por exemplo, “light”) e 24 proíbem o uso de figuras, cores e outros indicadores, mas apenas 13 proíbem a impressão do teor de emissões nas embalagens. Somente o Canadá e o Uruguai adotaram embalagens padronizadas para produtos de tabaco, e o Uruguai também exige uma única apresentação (uma variante de marca) por família de produto.

Conclusão.

Muitos países na AMR têm avançado na adoção de advertências sanitárias pictóricas, múltiplas, grandes e com rotatividade, bem como na proibição de termos enganosos nas embalagens. Porém, é preciso dar mais atenção a outras disposições sobre a embalagem e a etiquetagem dos produtos de tabaco, com foco na implementação de embalagens padronizadas.

Palavras-chave
Rotulagem de produtos derivados do tabaco; embalagem de produtos derivados do tabaco; regulamentação governamental; comunicação em saúde; América

The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) Article 11 establishes provisions on packaging and labeling for tobacco products, including health warning labels (HWLs), constituents and emissions (C&Es) information, removal of misleading information, and plain packaging.¹1. World Health Organization. WHO Framework Convention on Tobacco Control. Geneva: WHO; 2003. Available at: http://apps.who.int/iris/bitstream/10665/42811/1/9241591013.pdf. Accessed 12 November 2015.
http://apps.who.int/iris/bitstream/10665...

In November 2008, the third Conference of the Parties approved the guidelines for the implementation of Article 11, which are intended to assist parties in meeting their obligations under Article 11 and propose measures that parties can use to increase the effectiveness of their packaging and labelling measures.²2. World Health Organization. Guidelines for Implementation of Article 11 of the WHO Framework Convention on Tobacco Control (Packaging and Labeling of Tobacco Products) November 2008. Available at: http://www.who.int/fctc/guidelines/article_11.pdf. Accessed 10 April 2012.
http://www.who.int/fctc/guidelines/artic... As of September 2022, all of the countries in the WHO Region of the Americas (AMRO), except for Argentina, Cuba, Dominican Republic, Haiti, and the United States, have ratified the FCTC.³3. United Nations. Treaty Collection: WHO Framework Convention on Tobacco Control. May 2016. Available at: https://treaties.un.org/pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IX-4&chapter=9&lang=en
https://treaties.un.org/pages/ViewDetail... Within three years of ratification, parties are required to implement effective measures implementing FCTC Article 11.

A growing body of research examining tobacco packaging and labeling has helped identify best practices.⁴4. Noar SM, Francis DB, Bridges C, et al. The Impact of Strengthening Cigarette Pack Warnings: Systematic Review of Longitudinal Observational Studies. Soc Sci Med. 2016;164:118-29.

5. Skurka C, Kalaji M, Dorf MC, et al. Independent or Synergistic? Effects of Varying Size and Using Pictorial Images in Tobacco Health Warning Labels. Drug Alcohol Depend. 2019;198:87-94.-⁶6. Sillero-Rejon C, Mahmoud O, Tamayo RM, et al. Standardised Packs and Larger Health Warnings: Visual Attention and Perceptions among Colombian Smokers and Non-Smokers. Addiction. 2022;117(6):1737-1747. The FCTC recommends having multiple rotating HWLs and research further suggests rotations should occur periodically to avoid over exposure and the audience becoming desensitized from a single image.²2. World Health Organization. Guidelines for Implementation of Article 11 of the WHO Framework Convention on Tobacco Control (Packaging and Labeling of Tobacco Products) November 2008. Available at: http://www.who.int/fctc/guidelines/article_11.pdf. Accessed 10 April 2012.
http://www.who.int/fctc/guidelines/artic... While the FCTC recommends that textual messages highlight the harmful effects of tobacco use, pictures eliciting unfavorable emotional associations about tobacco use are more believable and convincing.⁷7. Hammond D. Health Warning Messages on Tobacco Products: A Review. Tob Control. 2011;20:327-37. In addition, the guidelines suggest messages on addiction, cessation advise, economic and social impact, environmental harms, and industry malpractice. The FCTC requires HWLs covering no less than 30% of the principal display areas (PDAs) of the package and research indicates that the effectiveness of pictorial HWLs increases the larger and more graphic the images are on the package.⁸8. Hammond D, Fong GT, McNeill A, et al. Effectiveness of Cigarette Warning Labels in Informing Smokers About the Risks of Smoking: Findings from the International Tobacco Control (Itc) Four Country Survey. Tob Control. 2006;15:iii19-iii25.

9. Hammond D, Fong GT, Borland R, et al. Text and Graphic Warnings on Cigarette Packages: Findings from the International Tobacco Control Four Country Study. Am J Prev Med. 2007;32:202-9.-¹⁰10. Devlin E, Anderson S, Hastings G, et al. Targeting Smokers Via Tobacco Product Labelling: Opportunities and Challenges for Pan European Health Promotion. Health Promot Int. 2005;20:41-9. The FCTC guidelines also recommend tobacco plain packaging, where the promotional elements of the pack are removed by requiring a standard dull color (usually green/brown) on all surfaces, apart from the brand name in a standard typeface and color and the required HWLs. We refer to tobacco plain packaging as tobacco standardized packaging. The implementation of standardized packaging has shown to help with smoking cessation efforts.¹¹11. Crosbie E, Thomson G, Freeman B, et al. Advancing Progressive Health Policy to Reduce Ncds Amidst International Commercial Opposition: Tobacco Standardised Packaging in Australia. Glob Public Health. 2018;13:1753-1766., ¹²12. Crosbie E. Removing the Last Billboard for the Tobacco Industry: Tobacco Standardized Packaging in Ireland. Health Policy. 2019;123:932-935. Research has previously documented the progress of cigarette packaging and labeling in Latin America and the Caribbean up until 2012.¹³13. Sebrie EM, Blanco A, Glantz SA. Cigarette Labeling Policies in Latin America and the Caribbean: Progress and Obstacles. Salud Publica Mex. 2010;52 Suppl 2:S233-43., ¹⁴14. Sebrie EM. Politicas De Etiquetado En Los Paquetos De Cigarrillos: Situacion Actual En America Latina Y El Caribe. Salud Publica Mex. 2012;5:293-302. This study aims to assess the adoption of all tobacco products packaging and labeling policies based on the FCTC’s Article 11 guidelines in all AMRO countries as of September 2022.

METHODS

Data collection

Between September 2021 and September 2022, we reviewed data on the regulatory environment of tobacco packaging and labeling in AMRO. Data was extracted from Tobacco Control Laws (www.tobaccocontrollaws.org), a database developed and maintained by legal advisors at the International Legal Consortium from the Campaign for Tobacco-Free Kids (CTFK) in collaboration with in-country lawyers, wherever possible. The database provides detailed legal analysis of national tobacco control laws adopted all over the world. Reviewers use legislative review templates and interpretation protocols to make determinations about the degree to which the legislation complies with the FCTC and aligns with its guidelines.

Of the 35 AMRO countries, four (e.g., Dominica, Haiti, Saint Kitts & Nevis, and Saint Vincent & the Grenadines) have not adopted any tobacco packaging and labeling legislation and eight (e.g., Bahamas, Belize, Cuba, Dominican Republic, Grenada, Nicaragua, Saint Lucia, and United States) adopted packaging and labeling laws, but the database does not provide their analysis. For these laws, two of the co-authors conducted the analysis separately using the same categories as the database templates to ensure consistency. Once the analysis was completed, we consulted with one of the legal advisors from CTFK to review our analysis.

Data analysis

Based on FCTC Article 11 and its implementing guidelines we organized the information within four sub-policy areas: 1) HWLs: type (text-only or pictorial), location (front and back or lateral), size (as a percentage of the PDAs of the pack), rotation period, number (single or multiple), principal language/s, message content areas, and quit resource information (i.e., a stop-smoking helpline and/or website); 2) Toxic C&Es descriptive information: size, location, rotation period, number, and message content; 3) Ban on misleading tobacco packaging and labeling : brand descriptors (e.g., “light”), emission yields (e.g., nicotine, tar, carbon monoxide), and figures, colors, and other signs; and 4) Standardized packaging. The analysis was applied to the different types of tobacco products (i.e., smoked and smokeless).

Finally, we developed a scoring system to rank countries according to the extent of adoption of the main measures included in Art. 11 guidelines. These measures include HWLs type (0: none; 1: text-only; 2: pictorial); location (0: lateral; 1: one PDA; 2: both PDAs); size (0: less than 30%; 1: 30 to 49%; 2: 50 to 74%; 3: 75% or more); rotation (0: not required; 1: not specified; 2: specified); number (1:1 message; 2: 2 or more messages); principal language/s (0: none; 1: partial; 2: full); message content (0: general or not specified; 1: 1 area; 2: 2 or more areas); quit information (0: no; 1: yes); C&Es rotation (0: not required; 1: not specified; 2: specified); number (1:1 message; 2: 2 or more messages); ban on brand descriptors (0: no ; 1: partial; 2: full); ban on emission yields (0: no ; 1: partial; 2: full); ban on misleading figures, colors (0: no; 1: partial; 2: full); and standardized packaging (0: no; 4: yes). The maximum total score that each country could obtain was 30 points.

RESULTS

Out of the 31 countries that have adopted tobacco packaging and labeling laws, 20 apply the same requirements to all types of tobacco products (smoked and smokeless), seven apply different requirements to smoked and smokeless tobacco products, and four only require them for either all smoked tobacco products or just cigarettes. Results are presented by the four sub-policy areas.

Health warning labels (Table 1)

Type. Twenty-one countries require HWLs with a combination of pictures and text printed on all tobacco products packs, whereas Mexico and Suriname require this type of warnings only on all smoked tobacco products. In addition, pictorial HWLs are required in Canada only on cigarettes and little cigars, and in the United States and Venezuela only on cigarettes. Five countries require text-only HWLs.

Size. Twenty-eight countries require a specific size of the front and the back of the packs with an average size that ranges from 12.5% (Guatemala) to 80% (Uruguay) of the PDAs of the package. Only Guatemala requires an average size of less than 30% of the PDAs, three countries (Cuba, Colombia, and Paraguay)between 30 and 49% of the PDAs, 22 countries between 50 and 74% of the PDAs, and finally 2 countries (Canada and Uruguay) of 75% or more of the PDAs. Brazil, Mexico, and Venezuela have an average size of 65% but with a smaller display area on the front (30%) compared to the back (100%). Canada, Mexico, and United States require different sizes for smoked or smokeless tobacco products (75% vs. 50%, 50% vs. 30%, and 65% vs 100% respectively). Dominican Republic, Bahamas, and Belize do not specify the size of the HWLs.

Location. Twenty-six countries require HWLs placed on both the front and the back of the packs. Guatemala only on the front, Cuba either on both or just one PDA, and Dominican Republic on the lateral side of the packs. Mexico is the only country that requires a different location of the HWLs for smokeless tobacco products (lateral). Bahamas, and Belize do not specify the location of the HWLs.

Number. Dominican Republic, Barbados, and Belize require a single warning. Seventeen countries require multiple HWLs for all tobacco products with a number that ranges from two (Paraguay and Peru) to 12 (Costa Rica and Trinidad & Tobago). Suriname requires multiple (6) HWLs only for smoked tobacco products, and Venezuela (12) only for cigarettes. Six countries (Canada, United States, Mexico, Grenada, Jamaica, and Saint Lucia) require a lower number of warnings for smokeless than for smoked tobacco products.

Rotation period. Twenty countries rotate their HWLs for all tobacco products within a specified period that ranges from 5 to 24 months. However, most of the countries have rotations within a 12-month period. Mexico rotates HWLs every 12 months for smoked and 18 months for smokeless tobacco, Grenada (up to 16 months) and Suriname (18 months) require a rotation only for smoked tobacco products, and United States only for cigarettes (12 months).

Principal language/s. Same requirements apply for both smoked and smokeless tobacco products. Twenty-seven countries require messages in only one principal language, either Spanish (Mexico, most of Central and South American countries, Cuba, and Dominican Republic), Portuguese (Brazil), or English (United States, Belize, Guyana, and most of the Caribbean countries). Only a few countries have HWLs written in two languages including Canada (English and French), Paraguay (Spanish and Guarani) and Suriname (English and Dutch).

Message content. The most common message content area is the health impact due to smoking or secondhand smoke. Health effects include a variety of specific types of cancer (e.g., lung, mouth, tongue, pharynx, larynx, esophagus, throat, bladder, kidney, liver, stomach, pancreas, colon, rectum, and breast), cardiovascular disease, stroke, blindness, impotence, gangrene, respiratory disease, premature aging, and reproductive health outcomes.. Some countries include messages with advice on cessation and some describe the addictive nature of nicotine. Economic and social impact or environmental harms are the least common content areas used in the HWLs. No country in the Region have adopted messages denouncing tobacco industry malpractice.

Most of the countries depict the same message content for both smoked and smokeless tobacco products. Only seven countries (Canada, United States, Mexico, Barbados, Grenada, Jamaica, and Saint Lucia) provide a different message (mostly health impact) for smokeless tobacco products. In addition, only Canada and the United States use different messages for different types of smoked tobacco products (cigarettes, cigars, and bidis).

Quit resource information. Same requirements apply for both smoked and smokeless tobacco products. Only nine countries (Canada, El Salvador, Honduras, Mexico, Argentina, Brazil, Chile, Ecuador, and Uruguay) require quit smoking information printed on smoked tobacco products, which include a quit line phone number and/or a website.

Toxic constituents and emissions descriptive information (Table 2)

Eleven countries require C&Es descriptive messages printed on all tobacco products packs, whereas eight additional countries require these messages only on smoked tobacco products. Laws in Chile and Venezuela apply only for cigarettes.

Size. Eleven countries refer to the size of the message as a percentage of a display area of the pack with a range from 50% (Bolivia) to 100% (Canada, Chile, Costa Rica, Grenada, Jamaica, Paraguay, Saint Lucia, and Venezuela). In addition, Honduras requires a specific size of 6.3 cm by 9 mm.

Location. Eighteen countries require that the C&Es messages be located on the lateral side of the packs. Mexico requires on the back, Ecuador on the back and lateral side, and Peru on the front and back of the packs.

Number of messages. Thirteen countries require only a single message. Only five countries require multiple messages including Antigua and Barbuda (6), Brazil (9), Canada (4), Ecuador (6), and Mexico (4).

Rotation period. Only three countries established a rotation of the messages including Antigua and Barbuda (every 24 months), Mexico (every 12 months), and Brazil (every 5 months).

Message content. The most common C&Es described in the messages include tar, nicotine, and carbon monoxide, which are grouped together in 13 countries. Additional C&Es include ammonia, arsenic, benzene, benzopyrene, butane, cadmium, chrome, formaldehyde, hydrogen cyanide, nitrosamines, phosphorus, polonium 210, and vinyl chloride Three countries list non-specific C&Es such as carcinogens (Canada and Ecuador), fine particles (Canada), heavy metals (Brazil), and toxics (Ecuador).

Ban on misleading tobacco packaging and labeling (Table 3)

Twenty-five countries prohibit misleading tobacco packaging and labeling on all tobacco products packs. In addition, Chile applies the ban for smoked tobacco products and Venezuela only for cigarettes.

Brand descriptors. Twenty-seven countries have banned any brand descriptors that could imply less harm including “extra”, “light”, “low in tar”, “mild”, “slim”, “smooth”, “soft”, “ultra”, and “ultra-light”.

Emission yields. The display of figures for emission yields including nicotine, tar, carbon monoxide, or any other emissions are banned in 13 countries.

Figures, color, and other signs. Twenty-three countries have banned figures, colors, and other signs (e.g., logos, brand images, etc.) that create a false impression that a tobacco product is less harmful that other tobacco product. In addition, in Brazil terms and symbols are banned; however, it is unclear whether the use of signs such as colors or numbers are also banned.

Standardized “plain” packaging (Table 3)

Only Canada and Uruguay have adopted standardized packaging for all tobacco products. The Canadian law includes a uniform color, which is drab brown (Pantone 448 C). The shape of the primary package is rectangular cuboidal when it is closed with six surfaces that meet at right angles and edges that are rigid, without rounding or beveling. Another requirement for pack shape is the slide and shell with a vertical opening mechanism. The slide and shell package edge must also be rigid without rounding or beveling. In addition, the size of the standardized package in Canada must conform to a height of between 72 mm and 77 mm, a width of between 81 mm and 106 mm, and a depth of between 15 mm and 18 mm. The required primary package material is a rigid cardboard.

On the other hand, the law in Uruguay requires a uniform color (Pantone 448 C) with a matte finish (equivalent to RGB 74 65 42). The shape of primary cigarette packaging according to the law is that these packs shall be rectangular prism-shaped, and the size shall be corresponding to a height of 80-90 mm, width of 40-60 mm, and depth of 15-25 mm, with a hinged or flip-top type opening. As in Canada, the pack material is cardboard. The standardized packaging policies in both countries differ in the color, the shape, and size of packs (height and width), and explicit statements on beveling or rounded edges. In addition, Uruguay requires a single presentation (one brand variant) per brand family, which requires tobacco companies to sell only one unique presentation of each cigarette brand.

Tobacco packaging and labeling ranking in AMRO (Table 4)

Following a scoring system to rank the countries according to the extent of adoption of the main measures included in FCTC Article 11 guidelines, nine countries top the list with scores from 26 (Uruguay) to 21 (Grenada, Jamaica, and Saint Lucia) out of 30 possible points, mostly due to adopting most of the main measures including standardized packaging. Eighteen countries have scores from 20 to 15 due to adopting some of the measures. Outside of the four countries that did not have tobacco packaging and labeling laws, the other four had the lowest scores, from eight (Guatemala) to two (Bahamas). Twenty-seven countries had a score of at least 15 points and the average score was 19.8 illustrating good compliance with FCTC Article 11 guidelines.

DISCUSSION

Several countries in AMRO now align with FCTC Article 11 by requiring pictorial and textual HWLs covering 50% or more of the PDAs on smoked and smokeless tobacco product packaging. Since the first adoption of pictorial HWLs printed on 50% of the PDAs of the tobacco pack in Canada in 2000, the rate of adoption doubled following the FCTC’s Article 11 guidelines in 2008. The number of countries with this type of HWLs increased from 8 (right before the adoption of the guidelines) to 24 countries ten years after, in 2018 (Figure 1).

Similarly, a majority indicate the number and frequency of rotations, as well as the principal language and content of the messages. However, only a few country-policies make a distinction in the message contents between smoked and smokeless tobacco products, using instead identical pictures and texts on both tobacco products. Only a few countries require quit information on tobacco packaging. Requiring this information can potentially increase the reach and equity of smoking cessation treatment,⁵5. Skurka C, Kalaji M, Dorf MC, et al. Independent or Synergistic? Effects of Varying Size and Using Pictorial Images in Tobacco Health Warning Labels. Drug Alcohol Depend. 2019;198:87-94., ⁶6. Sillero-Rejon C, Mahmoud O, Tamayo RM, et al. Standardised Packs and Larger Health Warnings: Visual Attention and Perceptions among Colombian Smokers and Non-Smokers. Addiction. 2022;117(6):1737-1747. as seen in Canada.¹⁸18. Baskerville NB, Brown KS, Nguyen NC, et al. Impact of Canadian Tobacco Packaging Policy on Use of a Toll-Free Quit-Smoking Line: An Interrupted Time-Series Analysis. CMAJ Open. 2016;4:E59-65.

Only 21 AMRO countries require descriptive messages on toxic C&Es and most of them refer to tar, nicotine, and carbon monoxide. Few of those countries include also other qualitative information such as specific carcinogens, heavy metals, or other toxics.

Over half of the AMRO countries prohibit the use of misleading descriptors such as “light”, “ultra-light”, and “low in tar” on tobacco product packaging. Nonetheless, there is room for improvement, as some countries still allow brand descriptors which have the potential of misleading consumers to think some tobacco brands are less harmful than others. Likewise, the tobacco industry uses other indicators such as imagery and color to indicate “reduced harm” products, which is often misleading.¹⁵15. Hammond D, Parkinson C. The Impact of Cigarette Package Design on Perceptions of Risk. J Public Health (Oxf.) 2009;31:345-53.

16. Mutti S, Hammond D, Borland R, et al. Beyond Light and Mild: Cigarette Brand Descriptors and Perceptions of Risk in the International Tobacco Control (Itc) Four Country Survey. Addiction. 2011;106:1166-75.-¹⁷17. Moodie C, Ford A, Mackintosh AM, et al. Young People’s Perceptions of Cigarette Packaging and Plain Packaging: An Online Survey. Nicotine Tob Res. 2012;14:98-105. Only 13 countries prohibit emission yields printed on the packs, which also could have the same effect as the misleading descriptors.

The present study also found that only two countries (Canada and Uruguay) require standardized packaging for tobacco products in AMRO. The adoption of tobacco standardized packaging in other countries has shown to reduce the appeal and attractiveness of tobacco packaging and labeling features, especially among youth¹⁹19. MacGregor A, Delaney H, Amos A, et al. ’It’s Like Sludge Green’: Young People’s Perceptions of Standardized Tobacco Packaging in the UK. Addiction. 2020;115:1736-1744. and if adopted comprehensively, can potentially reduce the prevalence of smoking in the Americas.⁴4. Noar SM, Francis DB, Bridges C, et al. The Impact of Strengthening Cigarette Pack Warnings: Systematic Review of Longitudinal Observational Studies. Soc Sci Med. 2016;164:118-29.

5. Skurka C, Kalaji M, Dorf MC, et al. Independent or Synergistic? Effects of Varying Size and Using Pictorial Images in Tobacco Health Warning Labels. Drug Alcohol Depend. 2019;198:87-94.-⁶6. Sillero-Rejon C, Mahmoud O, Tamayo RM, et al. Standardised Packs and Larger Health Warnings: Visual Attention and Perceptions among Colombian Smokers and Non-Smokers. Addiction. 2022;117(6):1737-1747.

Assessing tobacco packaging and labeling in AMRO also provides important sub-regional takeaways. First, there are clear leaders for each of the four sub-regions including Canada (North America), Mexico (Mexico/Central America/Spanish Caribbean), Uruguay (South America), and Antigua and Barbuda (CARICOM). Second, the sub-regions of North America, and South America are the most advanced with all the countries having adopted the largest pictorial HWLs. The sub-region of the CARICOM is the least advanced with 2 countries with single lateral text-only HWLs, and the only 4 countries without any tobacco packaging and labeling laws.

Given the progress of implementing FCTC-based tobacco packaging and labeling policies in AMRO, future research should assess tobacco packaging and labeling as it pertains to emerging nicotine and tobacco products such as electronic nicotine delivery systems and heated tobacco products, which are increasingly available in the Region. With the existence of new databases and reporting, this analysis could be replicated to examine the progress of tobacco packaging and labeling laws and identify gaps and challenges in other regions, most notably Africa and Southeast Asia.

This study had some limitations. It only analyzed the adoption of tobacco packaging and labeling laws and not their implementation and enforcement, thereby limiting our ability to examine the level of compliance. We included only independent AMRO countries recognized by the United Nations but not any other jurisdictions located geographically within the region (e.g., Greenland in North America, French Guiana in South America, and many islands located in the Caribbean Sea under jurisdiction of European countries).

In conclusion, most of AMRO countries have adopted many tobacco packaging and labeling policies that align with FCTC Article 11, specifically, regarding rotating large pictorial HWLs, and banning misleading brand descriptors. However, only two countries in the Region have adopted tobacco standardized packaging.

Disclaimer.

Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the Revista Panamericana de Salud Pública / Pan American Journal of Public Health and/or those of the Pan American Health Organization.

Acknowledgements.

We thank Kaitlin Donley, a member of the International Legal Consortium with the Campaign for Tobacco-Free Kids, for reviewing the co-authors’ analysis of those countries not provided by the Tobacco Control Laws database, and for providing comments to the manuscript.

REFERENCES

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