The Thirdhand Smoke Resource Center responded to the FDA’s request for public comment on their proposed rule for graphic warnings for cigarette packages and advertising. The Center supports the proposed rules to help reduce population-wide exposure to toxic first-, second- and thirdhand smoke. Specifically, the Center proposes to add an additional graphic warning that focuses on toxic tobacco smoke residue that lingers in indoor environments where tobacco has been used and its health risk for children. Read the full comment here.

By: Thirdhand Smoke Resource Center
October 15, 2019  

Docket No: FDA-2019-N-3065; Tobacco Products; Required Warnings for Cigarette Packages and Advertisements  
We appreciate the opportunity to comment on the proposed rule requiring new graphic warnings for cigarette packages and advertisements. The  Thirdhand Smoke Resource Center (thirdhandsmoke.org) engages in public outreach and research dissemination for the Thirdhand Smoke Research Consortium established by California’s Tobacco-Related Disease Research Program. The Consortium brings together a variety of scientific disciplines and institutions throughout California to advance our understanding of the  toxic nature of tobacco smoke residue (i.e., thirdhand smoke) and its impact on human health. 
 
As an organization working to protect Californians from exposure to toxic tobacco smoke residue, our Center fully supports the proposed rule that would implement large, graphic health warnings on cigarette packages and advertisements, fulfilling a core provision of the Family Smoking Prevention  and Tobacco Control Act. We believe that the proposed graphic health warning labels will be an effective measure in reducing population-wide exposure to toxic first-, second-, and thirdhand tobacco smoke. 
 
We also suggest that an additional warning focused on the dangers of toxic tobacco residue to children will increase the public’s awareness of tobacco-related health risks and further protect youth from tobacco exposure. This conclusion is based upon extensive evidence supporting the effectiveness of warning labels in educating smokers and influencing their behaviors, as well as sufficient evidence suggesting toxicants present in tobacco residue harm children as detailed below. Peer-reviewed research about thirdhand smoke pollution and exposure can be found at thirdhandsmoke.org/research/ 

1. Evidence shows that large and pictorial health warning labels are effective in providing health information to the public and in increasing the knowledge of health risks of smoking, particularly regarding lesser known health effects.
Research has consistently found that large health warnings that contain both pictures and words on tobacco packages are more effective at increasing knowledge about risks associated with smoking than text alone (1,2). Over 120 countries around the world have already finalized requirements for large, graphic health warnings on cigarette packages, making it one of the most widely adopted and cost­ effective means to increase public awareness about the dangers of tobacco use (3), Moreover, warnings have proven effective at increasing public knowledge about lesser known health risks of smoking which can further discourage smoking (4).

2. Large, pictorial health warning labels can motivate smokers to quit, discourage nonsmokers from starting, and keep ex-smokers from starting again, reducing the overall prevalence of tobacco use within a population and exposure to secondhand smoke.
In recent years, growing evidence demonstrates that, in comparison to text-only warnings, graphic health warnings discourage nonsmokers from starting, motivate smokers to quit, and keep ex-smokers from starting again resulting in overall decreases in tobacco consumption (2,5,6). For example, a number of studies on the impacts of graphic health warnings on smoking-related outcomes conducted in Canada have documented that they reduced smoking prevalence and increased quit attempts (7,8,9). Graphic warning labels have also been found to reduce exposure to secondhand smoke (10) and, therefore, can also result in less toxic tobacco residue in environments where children and other vulnerable groups live and work.

3. Warnings with children elicit strong emotional reactions.
Pictorial health warnings that elicit strong emotional reactions are significantly more effective and those relating to children are amongst the most powerful/persuasive(1,2,11). For example, research conducted in the European Union found that respondents were deeply moved by images of sick kids (11). However, most of the study participants already knew about the effect of passive smoking on other people and some explained that they already move away from non-smokers to smoke, reducing the impact of general statements related to secondhand smoke risks.

4. An additional warning about the risk of latent tobacco smoke residue for children could increase public awareness of the risk posed by toxic thirdhand smoke and challenge perceptions that simply moving away from children when one smokes is sufficient.
Based on the evidence presented above, we recommend that an additional warning about the health risks associated with latent tobacco smoke residue to young children would significantly increase public knowledge about the harms of tobacco use. Increased awareness about the pervasiveness and persistence of toxic tobacco residue on smokers’ hands, clothes and surrounding environment (e.g. furniture, carpet, car) and related health risks to children would further encourage smokers to quit rather than move away from children while actively smoking. Such a warning is scientifically warranted given the existing evidence-based concerning the composition of toxicants present in latent tobacco smoke, and strong experimental evidence on DNA damage and functioning of cell health (12).   

References:

1. Hammond D. Health warning messages on tobacco products: a review Tobacco Control.  2011;20:327-337. 
2. Noar SM et al. Pictorial cigarette pack warnings: a meta-analysis of experimental studies. Tobacco Control. 2016;25:341-354. 
3. Canadian Cancer Society, Cigarette Package Health Warnings: International Status Repot, Sixth Edition, September 2018.
4. Hammond D 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. Tobacco Control. 2006 Jun;15 Suppl 3:iii19-25. 
5. Skurka C., Kemp D., Davydova J., Thrasher J.F., Byrne S., Greiner Safi A., Avery R.J., Dorf M.C., Mathios A.O., Scolere L., et al. Effects of 30% and 50% Cigarette Pack Graphic Warning Labels on Visual Attention, Negative Affect, Quit Intentions, and  Smoking Susceptibility among Disadvantaged Populations in the United States. Nicotine Tob. Res. 2017;1:8. doi: l0.1093/ntr/ntx244. 
6. Shang C., Huang J., Cheng K.W., He Y., Chaloupka F.J. The Association between Warning Label Requirements and Cigarette Smoking Prevalence by Education-Findings from the Global Adult Tobacco Survey (GATS) Int. J. Environ. Res. Public Health. 2017;14:98. doi: 10.3390/ijerph14010098. 
7. Azagba S., Sharaf M.F. The Effect of Graphic Cigarette Warning Labels on Smoking Behavior: Evidence from the Canadian Experience. Nicotine Tob. Res. 2013;15:708- 717. doi: 10.1093/ntr/nts194. 
8. Hammond D., Fong G.T., McDonald P.W., Cameron R., Brown K.S. Impact of the graphic Canadian warning labels on adult smoking behaviour. Tob. Control. 2003;12:391-395. doi: 10.1136/tc.12.4.391. 
9. Huang J.D., Chaloupka F.J., Fong G.T. Cigarette graphic warning labels and smoking prevalence in Canada: A critical examination and reformulation of the FDA regulatory  impact analysis. Tob. Control. 2014;23:7- 12. doi: I0.1136/tobaccocontrol-2013-051170. 
10. Chang F et al. The impact of graphic cigarette warning labels and smoke-free law on health awareness and thoughts of quitting in Taiwan. Health Education Research. 2011;26(2):179-191.
11. European Commission. Eurobarometer Qualitative Study: Tobacco Packaging Health Warning Labels, An Aggregate Report. March 2012. Accessed October 11, 2019 at https://ec.europa.eu/health/sites/health/fi les/to bacco/docs/eurobaro tobaccowarninglabels qi 5818 en.p df 
12. Bo H, Wang P, Zhao Y, Sarker A, Chenoa A, Xia Y, Snijders A, Mao JH. Adverse Health Effects of Thirdhand Smoke: From Cell to Animal Models. International Journal of Molecular Sciences. 2017; 8(5). Doi: 10.3390/ijms18050932. 

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