This cross-country study of tobacco packaging and labeling laws showed that even countries that have ratified the FCTC are yet to align their laws to the highest standards of the FCTC article 11, especially with regard to the diversity of the content of health warnings, location of health warnings on the PDA of packs, and prohibition of misleading descriptors on cigarette packs.
It is important that health warning messages continue to reflect the extensiveness of the effects tobacco use can have on its users and those around them. Tobacco companies have historically obfuscated the facts about the addictive nature of nicotine, as well as the far-reaching adverse effects of smoking on health and the environment . Consequently, many smokers, including non-smokers, have underestimated the extreme addictive nature of nicotine and the impact of their smoking habit on their health and those around them [16, 17]. A combination of warnings that cover issues on health effects of smoking with adverse social and economic outcomes, addictive nature of nicotine, cessation and the impact of smoking on family and friends, as required by the FCTC, can be more powerful in convincing individuals who differ in what motivates them to initiate or quit smoking.
This study also detects a consistent weakness with respect to location of health warnings. Many countries do not require that health warnings be placed at the top of the principal display area. In addition, many country laws do not require health warnings to be located where they would not be obstructed by required markings on packs, or damaged/concealed with the opening and closing of packs. Most countries in the selection (except Mexico, Spain, Turkey, Nepal and Australia) do not meet all the requirements for location of health warning labels as required by the FCTC. Though large warnings have been shown to be effective by both smokers and non-smokers [18, 19], placing them at the top of the PDA can further enhance their effectiveness and noticeability.
Most country laws in the selection did not prohibit the use of all forms of misleading descriptors on packs, except Australia and Mexico, which comply with all the requirements of the FCTC with respect to this category. Countries' laws were especially weak in prohibiting the display of quantitative emission yields on their packs. Users of these products may still ascribe lower risks to brands that have lower levels of tar, carbon monoxide or nicotine, attenuating the effect that the prohibition of the use of misleading terms such as “mild” “light”, may have had.
Six countries in the selection (South Africa, Kenya, Poland, Indonesia, Philippines and China) are yet to mandate the use of health warnings that contain pictograms. It is also important to note that most of these are low-and middle-income countries, where health literacy may be relatively low. Though the use of pictograms is not a requirement, countries can strengthen the impact of their warning labels by using graphic color images. Strong warnings that utilize graphic pictograms, and not just text, are shown to be more effective in getting the attention of users, conveying the significance of the text warning and ultimately inducing a change in the perception of risk by the users [18, 20–27]. Studies have shown that smokers tend to notice health warnings with pictures more than they do warnings without [21, 28]. Pictograms would convey a stronger message, especially in low-literacy settings, or in cases where text warnings are very weak in conveying the harms of tobacco use.
Strong health warning messages can influence the decision to initiate or quit smoking [5, 6], and these measures can be implemented at no cost to governments . Some countries like Canada [19, 29, 30], Australia , Brazil , Singapore  and Thailand  have seen significant change in perceptions and attitudes toward smoking following implementation of some of these FCTC-recommended best-practices in health warning display. Barriers to implementing best practices in tobacco packaging and labeling, as stipulated by the FCTC, would vary by country. Countries should share their successes and challenges, and collaborate on possible strategies to strengthen their tobacco laws. Sustained efforts to enact, mandate and enforce the evidence-driven guidelines outlined by the FCTC will enable countries to protect the health of their citizens and reduce mortality and illness from tobacco.
Strengths and limitations
This study examines tobacco packaging and labeling legislation in countries that contribute the most numbers of smokers to the global burden from smoking across all six WHO regions. However, these findings are subject to at least four limitations. First, unofficial translations of country tobacco laws  were used to assess compliance with the FCTC provisions. Due to limitations of translation, certain wordings or expressions may not be accurately represented. However, these translations were carefully verified by in-country lawyers and experts, as well Campaign for Tobacco-Free Kids staff in Washington DC, and give a clear understanding of country tobacco laws. Second, this study examines tobacco regulations as written, not as practiced. Some countries may actually meet the FCTC requirements in practice, even though their laws do not. For example, Canada’s health warnings are placed at the top of the PDA, even though this is not specified in the legislation. Conversely, some countries may have laws that are compliant with the FCTC requirements, but are not enforced. Some examples include Vietnam and the US, whose new laws have not yet come into full effect. Third, this study examines laws that pertain only to manufactured cigarettes. Fourth, the unavailability of verified translations of laws in many African and Eastern Mediterranean countries prevented us from including more countries from these regions in this study.