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Public health benefits from pictorial health warnings on US cigarette packs: a SimSmoke simulation
  1. David T Levy1,
  2. Darren Mays1,
  3. Zhe Yuan1,
  4. David Hammond2,
  5. James F Thrasher3
  1. 1 Department of Oncology, Cancer Prevention & Control Program, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC, USA
  2. 2 School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
  3. 3 Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, South Carolina, USA
  1. Correspondence to Dr David T Levy, Department of Oncology, Cancer Prevention & Control Program, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington DC 20007, USA; DL777{at}


Introduction While many countries have adopted prominent pictorial warning labels (PWLs) for cigarette packs, the USA still requires only small, text-only labels located on one side of the cigarette pack that have little effect on smoking-related outcomes. Tobacco industry litigation blocked implementation of a 2011 Food and Drug Administration's (FDA) rule requiring large PWLs. To inform FDA action on PWLs, this study provides research-based estimates of their public health impacts.

Methods Literature was reviewed to identify the impact of cigarette PWLs on smoking prevalence, cessation and initiation. Based on this analysis, the SimSmoke model was used to estimate the effect of requiring PWLs in the USA on smoking prevalence and, using standard attribution methods, on smoking-attributable deaths (SADs) and key maternal and child health outcomes.

Results Available research consistently shows a direct association between PWLs and increased cessation and reduced smoking initiation and prevalence. The SimSmoke model projects that PWLs would reduce smoking prevalence by 5% (2.5%–9%) relative to the status quo over the short term and by 10% (4%–19%) over the long term. Over the next 50 years, PWLs are projected to avert 652 800 (327 000–1 190 500) SADs, 46 600 (17 500–92 300) low-birth-weight cases, 73 600 (27 800–145 100) preterm births and 1000 (400–2000) cases of sudden infant death syndrome.

Conclusions Requiring PWLs on all US cigarette packs would be appropriate for the protection of the public health, because it would substantially reduce smoking prevalence and thereby reduce SADs and the morbidity and medical costs associated with adverse smoking-attributable birth outcomes.

  • Packaging and Labelling
  • Public policy
  • Surveillance and monitoring

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  • Twitter Follow Darren Mays at @darren_mays

  • Collaborators Erric Lindblom.

  • Contributors All authors have contributed to the formulation of the model and the writing of the original manuscript and revisions.

  • Funding Funding was received by DTL from the National Institute on Drug Abuse, under grant R01DA036497, to examine health warnings and from the Cancer Intervention and Surveillance Modeling Network (CISNET) of the Division of Cancer Control and Population Sciences, NCI under grant UO1-CA97450 to develop the SimSmoke model. JFT was partly supported by a grant from the National Institutes of Health (R01 CA167067). The funders had no role in the design, analysis, preparation, or decision to publish the manuscript.

  • Competing interests DH and JFT have served as a paid expert witnesses on behalf of governments in tobacco litigation, including challenges to health warning regulations.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The CISNET data used to develop the model is available on the NCI CISNET website.