Why Doesn't The USA Have Graphic Warning Labels On Cigarette Packs Like The Netherlands?

While strolling the delightful (and typically debris-free) streets of Haarlem in The Netherlands the skeptical cardiologist espied an unusual cigarette pack on the ground.
In comparison to the typical American cigarette pack I noted a very prominent and disgusting picture of a leg which had been ravaged by peripheral artery disease.
The large print translates “smoking clogs your arteries.”
This is one of many potential warnings on Dutch cigarette packs. My favorite is
Roken kan leiden tot een langzame, pijnlijke dood
(Smoking can lead to a slow, painful death)
Perhaps, if such warning had been on American cigarette packs in the 1990s my mother would have been able to walk without severe pain in her legs (claudication) from the severe blockages caused by her decades of cigarette smoking.
When cigarette smoking patients tell me that “you have to die from something” I tell them that although they are greatly increasing their chance of dying from lung and cardiac disease, the smoking may not kill them but  leave them miserable and unable to walk or breath.
Experts on tobacco control note that these large, graphic and direct warnings are much more effective than the first small boxed warnings:

After the implementation of the first warning labels in 1966, the FTC’s 1981 report concluded that the original warning labels were not novel, overexposed and too abstract to remember and be personally relevant.46 Warning labels, like advertisements, wear out over time.47 Written warning labels wear out faster than graphic ones.48,49 In response, Congress passed a law mandating four rotating warnings. Studies on them began appearing in the late 1980s, demonstrating that several years after the implementation, those written labels on cigarette packs were also not noticed and not remembered by smokers and adolescents.5053 Since then, the diffusion and evolution of tobacco warning labels have been propelled by observational and experimental studies showing the effectiveness of large graphic warning labels in informing consumers about the health harms of smoking and reducing their smoking behavior.45,54

Here’s how Australia’s warnings have evolved
In 2011 the US Congress passed legislation moving America towards such effective graphic warnings:
However, the law was challenged by Big Tobacco and has never been enacted. From the FDA site:

The Family Smoking Prevention and Tobacco Control Act requires the FDA to include new warning labels on cigarette packages and in cigarette advertisements. On June 22, 2011, the FDA published a final rule requiring color graphics depicting the negative health consequences of smoking to accompany the nine new textual warning statements. However, the final rule was challenged in court by several tobacco companies, and on Aug. 24, 2012, the United States Court of Appeals for the District of Columbia Circuit vacated the rule on First Amendment grounds and remanded the matter to the agency.[1] On Dec. 5, 2012, the Court denied the government’s petition for panel rehearing and rehearing en banc. In 2013, the government decided not to seek further review of the court’s ruling.
The FDA has been undertaking research related to graphic health warnings since that time.
[1] R.J. Reynolds Tobacco Co., et al., v. Food & Drug Administration, et al., 696 F.3d 1205 (D.C. Cir. 2012)

What Other Countries Are Doing

According to a Canadian Cancer Society report from late 2016,

More than 100 countries/jurisdictions worldwide have now required pictorial warnings, with fully 105 countries/jurisdictions having done so. This represents a landmark global public health achievement.

Increasingly, the United States stands alone, because of a constitutional doctrine privileging commercial speech above public health.
Here are the countries requiring pictorial warnings courtesy of that Canadian Cancer Society report.

And some of their warning pictures:

And this a picture that FDA would have required:

Skeptically Yours,


11 thoughts on “Why Doesn't The USA Have Graphic Warning Labels On Cigarette Packs Like The Netherlands?”

  1. I believe that graphic picture health warnings do work, Hence why the tobacco companies are so worried about them in certain countries they are tried to stop them through the courts.If I could I would have warnings like Smoking is highly addictive(most smokers regret ever starting) Smoking causes bad breath, tooth decay, gum disease and tooth loss, Smoking causes 90% of all lung cancer deaths, Smoking causes gangrene and amputation, 1 in every 2 Smokers will die from
    a smoking related illness, Smoking causes stomach cancer,
    Smoking causes throat cancer, Smoking is a major cause of blindness,
    Smoking during pregnancy causes birth defects, miscarriage, stillbirth
    and sudden infant death aka cot death, Smoking causes emphysema for which there is no know cure ,Smoking causes heart attacks.

  2. This just spotted while traveling in Belgium: https://www.instagram.com/p/BbPpRaLlD8X/?taken-by=modernmediterranean.
    I hadn’t seen these graphic anti-smoking packages until now and find them very shocking and effective (but then, I’m not a smoker). Does data show that graphic anti-smoking ads reduce smoking? Or is it the punitive taxes?
    I must say, I’ve smelled a lot more smoke while here in Europe than I do in Colorado, where it has become a very rare occurrence. (Then again, I live in health-freak central, Boulder.) Maybe people become inured to the pictures?

  3. Re vaping: I imagine that it is significantly less harmful than is intentionally inhaling the smoke from burning leaves and paper. Nicotine may be a deadly toxin and largely responsible for the addictive effects of smoking but it is, in itself, not evidently responsible for the morbidities and death that are caused by inhalation of burning cigarettes.
    I worry that amongst the proliferating multitudes of untested agents for novel vapor flavor and smell that are added to “vape juice” there may be carcinogens and worse (if there be a “worse”)

  4. To my favorite woman who still smokes. Please read. I quit after twenty years on the day my father who smoked was diagnosed with terminal lung cancer. It was eight months later that my skeleton of a father died at a younger age than Janet. Do yourself a favor and just quit. No patch or meds. Just do it. You know you can.
    George P.

    • And George, it’s easier if she switches to vaping. Unfortunately Tobacco Control are trying to stop that too by foul means mainly by means of fear propaganda. Switching to vaping is much more successful than patches or gum for stopping smoking. The UK is leading the way on realising the benefits of vaping for smokers at the moment and much good proper science has been done on it.

  5. I consider them criminal! They are gross medical porn and must have a subliminal nocebo effect on everyone who sees them. I wonder if smoking kills LESS in the USA than countries who use these images? Some of the images used are not even smoking related! Kids collect them, like the old cigarette cards. Yet no one every speaks out. Here,in UK ‘smoking’ is not defended in any way. It’s an invisible pleasure, never mentioned, secret, shameful, despicable. The aim of Tobacco Control is the ENDGAME to rid the world of smokers by any means, fair and foul. Mostly, it’s foul!
    Thanks for an interesting article. I have shared.

  6. In Aus here and they do work but not on their own. Addiction still needs to be treated comprehensively but these packaging pictures help drive the want to quit in some people. In addition we have very hefty taxes which increase yearly. A carton of smokes costs around two hundred dollars Aus. Affordable vapour inhalers are the way to go as part of the array of supports.

    • Ha ha, have a holiday in Australia and you will see, in my case I can smell someone smoking twice or three times a year, I just return home from a two hour walk mainly along a main road and the only thing I was able to smell was flowers (spring here) and the traffic
      The last figures (2013) than I have are than 13% of the people smoke and people than never smoked was 60% and that was 4 years ago.
      Sure it is not only the label/packaging, but as well taxes, and other regulations than made the change

  7. I’m sure Congress will do something about this. (not)
    PS France’s warning labels are pretty gross too. We do stand alone.


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