BACKGROUND: In compliance with World Health Organization Framework Convention on Tobacco Control (WHO-FCTC) Article 11, health warning labels (HWLs) on unit packets of tobacco products serve as an essential element of enforcing tobacco control policies and disseminating anti-tobacco messaging. This study attempts to find if there is an association between HWLs on cigarette packages and prevalence of smoking among adults in low- and middle-income economies (LMICs).
METHODS: Country-level data on age-standardized prevalence rates for adult daily smokers of tobacco (both sexes combined) and HWLs on cigarette packages were taken from regional summary of WHO report on the global tobacco epidemic, 2023. Country classification by World Bank for fiscal year 2025 was used to identify LMICs across regions. Score of 1-4 was assigned to health warnings set by individual countries and a cut-off rate was considered to demarcate low and high prevalence. Descriptive statistics and bivariate analysis were used to draw comparisons across regions and examine associations between HWL scores and prevalence rates.
RESULTS: A moderate association exists between HWL scores and prevalence rates in lower middle-income countries with Cramer’s V of 0.33. Prevalence rates were <15% in three-fourths of LMICs across all regions and 41% of them had large HWLs with all appropriate characteristics. More than 70% of LMICs in East Asia and Pacific region had large HWLs. Nonetheless, three-fourths of them had prevalence rates between 15%-30%. Every LMIC in sub-Saharan Africa and Latin America and Caribbean region had a prevalence rate of <15% irrespective of individual HWL scores. Region-specific analysis incorporating country indicators helps to capture underlying association between HWLs and prevalence rates.
CONCLUSIONS: Countries’ demographic characteristics are important factors in explaining observed prevalence rates. Implementation of HWLs necessitates appropriate policies especially in highly populated countries albeit with low prevalence rates e.g. India due to greater reach in absolute number of smokers.