With its decision to add graphic warning labels to cigarette cartons -- and this week's announcement of what those labels will look like, the U.S. Food and Drug Administration has evoked cheers from many people, including public health experts.
But the move has also raised eyebrows. Sure, images of a post-autopsy cadaver or of a man blowing smoke through a hole in his neck may disgust, even scare potential smokers, especially when accompanied by phrases like "Tobacco smoke can harm your children" and "Smoking can kill you."
But how much of a difference can a bunch of explicit images actually make in how people choose to behave?
In fact, experts say, there is plenty of scientific data to support the new labels, including evidence from some 30 nations that have been using graphic imagery to discourage tobacco use for as much as many as 10 years or more.
Warning labels alone won't stop or prevent Americans from smoking when they begin to appear in 2012, said Geoff Fong, a global health researcher at the University of Waterloo in Canada. But images can be a powerful and positive step in the anti-smoking direction.
"Our results suggest that graphic warning labels significantly enhance paying attention to warnings," Fong said, who has studied the impact of a variety of anti-smoking efforts in more than 20 countries around the world.
"Beyond that are more negative attitudes toward tobacco and cigarettes, greater knowledge about the harms of cigarettes depicted in those warnings and an increased motivation to quit," he said.
"People are going to say this is inappropriate or going too far," he added, before quoting Canadian anti-smoking advocate Garfield Mahood, executive director of Canada's Non-Smoker's Rights Association: "'Well, you tell me,' Garfield said, 'What kind of warning label would be appropriate for a consumer product that kills half of its users?'"
Labels that warn people about tobacco's hazards have graced the packages of cigarettes, cigars and other tobacco products for more than 40 years. Labeling started in the mid-60s, with a mild note of caution that smoking might be hazardous to health. In 1970, the Surgeon General added a more stern warning that confirmed the danger.
In 1985, labels grew more specific. The Surgeon General issued four separate warnings that tobacco companies were required to rotate on their packaging. One mentioned lung cancer, heart disease and emphysema. Another referred to the dangers of smoking during pregnancy. Those same labels have been on tobacco products ever since.
But evidence has suggested that the language on these warnings isn't reaching everyone, said Pam Bradley, Director of Science Policy at the American Association for Cancer Research in Washington, D.C. People fail to notice the messages. They don't absorb the information.
Once other countries have switched to graphic warning labels, on the other hand, results have been dramatic.
"There is a slew of evidence from other nations that have already this," Bradley said. "Large color graphics are so much more effective than the textual warnings we've had for the past 25 years."
One Institute of Medicine study, referenced by the FDA, found that 85 percent of Canadian respondents used tobacco packages as a source of health information, compared to 47 percent of American smokers. Canada was the first country to adopt large, graphic warning labels in late 2000.
Studies have also shown that people are most likely to notice and remember colorful images and extra-large pictures that take up much of the packaging. It is also important to rotate images so that people don't get too used to them.
Perhaps the strongest evidence for the new labels comes from the International Tobacco Control Evaluation Project, which has examined tobacco-control policies around the world.
After Thailand switched to graphic labels in 2005, for example, the project found that the percentage of smokers who reported thinking about health risks because of the warnings went up from about 35 percent to 55 percent. The percentage of smokers who said that the warnings made them more likely to quit rose from 31 percent to 46 percent.
During the same period in Malaysia, which retained its small text-box labels, there was no change in the effect of warnings on attitudes about health risks, which hovered around nine percent. The likelihood that warning labels might induce people to quit there actually went down slightly from 14 percent to nine percent.
In Mauritius, likewise, the percentage of smokers who said they frequently noticed warnings on packages rose from 56 to 83 percent after a switch to graphic labels.
"We have found this in virtually every country in which graphic labels have been introduced," said Fong, who is principal investigator for the ITC project. "Graphic labels work, and the reason why they work is the same reason why advertisers use vivid images in their pro-tobacco communication to consumers. What the FDA is doing now is trying to level the playing field a little bit."
Overall, ITC studies show, taxing and otherwise raising the price of tobacco products is the most effective way to dissuade people from buying them. But, Fong said, graphic labels are also helpful, along with other strategies like smoke-free bans and marketing restrictions.
Vivid images, in particular, tend to elicit emotional reactions, which have been shown to be powerful motivators. The FDA has estimated that the new labels will discourage more than 200,000 smokers in the first few years after they appear, Bradley said.
More than 440,000 Americans die from smoking-related diseases every year, making tobacco the single most preventable cause of death in the country.