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Rotation of tobacco health warnings and messages: challenges and recommendations for implementation
  1. Fernanda Alonso1,
  2. Joanna E Cohen2
  1. 1Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
  2. 2Institute for Global Tobacco Control, Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
  1. Correspondence to Dr Fernanda Alonso, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; falonso1{at}


Health warnings and messages—or health warning labels (HWLs)—are integral to tobacco control efforts, but their sustained impact necessitates regular rotation. This paper explores challenges in HWL rotation implementation across six diverse countries: Chile, Guyana, Indonesia, Jamaica, Mexico, and Vietnam. 19 in-depth interviews were conducted with government officials and representatives from civil society organisations and academia. Interviews explored the effectiveness of HWL regulations, the processes involved in their execution, and any challenges encountered along the way. Interviews were analysed thematically, using a combination of deductive and inductive approaches. Interviews revealed critical challenges that fall into two categories: specific and overarching. Government priorities and transitions, political will, time and bureaucracy, legal loopholes, lack of images, evaluation, and economic and human resources constitute HWL-specific challenges. Broad tobacco control challenges included tobacco industry interference and enforcement difficulties. To address HWL rotation challenges, international bodies such as WHO could establish extensive image banks, pre-evaluated for effectiveness and cultural relevance. In addition, countries must institutionalise the rotation process by establishing mechanisms that avoid having to pass complex legal instruments with each new round of warnings, delegating responsibilities to stable government institutions, addressing legal loopholesand planning for multiple rounds within a single legal instrument. Further, partnerships at national and international levels, along with systematic evaluations, are crucial for successful HWL implementation. These recommendations form a comprehensive framework for global collaboration, aiming to strengthen tobacco prevention through impactful HWLs on a sustainable basis.

  • Global health
  • Low/Middle income country
  • Packaging and Labelling
  • Public policy
  • Tobacco industry

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  • Contributors Both authors conceived the original idea and design of the study. FA carried out the interviews and coding. Both authors analysed the data and FA drafted the initial manuscript with support from JEC. Both authors contributed to the final version of the manuscript. JEC supervised the project. Both authors helped shaped the research, analysis and manuscript and approved the final draft.

  • Funding This work was supported by Bloomberg Philanthropies’ Bloomberg Initiative to Reduce Tobacco Use.

  • Competing interests The authors are paid consultants in litigation against a tobacco company.

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