These are just a few of the 36 new warning labels for cigarette packages recently proposed by the federal government.
Designed to cover half the surface area of a pack or carton of cigarettes, and 20 percent of any advertisements for them, the labels are intended to spur smokers to quit and stop others from starting by providing graphic reminders of tobacco's dangers. The new labels are required under a law passed last year that gave the Food and Drug Administration the power to regulatebut not bantobacco products for the first time.
"This is the most important change in cigarette health warnings in the history of the United States," says Matthew L. Myers, president of the Campaign for Tobacco-Free Kids.
Public-health officials hope the new labels will re-energize the nation's antismoking efforts, which have recently stalled. Almost 21 percent of American adults, or 46.6 million people, and about 20 percent of high school students, or 3.4 million teenagers, are smokers.
$96 Billion a Year
Every day, about 1,000 children and teenagers become regular smokers, and 4,000 try smoking for the first time. About 440,000 people die every year from smoking-related health problems, and the cost to treat such problems exceeds $96 billion a year.
Some cigarette manufacturers vowed to fight the labels in federal court, saying they infringe on the companies' property and free-speech rights. A federal judge in Kentucky ruled in January on a related lawsuit that the F.D.A. could require graphic warning labels. That ruling has been appealed. Tobacco companies are also fighting bigger health warnings in South America, as well as limits on cigarette advertising in Britain.
Among the most arresting of the proposed labels is one in which a man exhales smoke through a hole in his neck. Some smokers who suffer from cancer of the larynx must breathe through a tracheotomy instead of through their noses and mouths.
The origins of tobacco go back to Native Americans, who introduced the crop to Colonial settlers in the 17th century. Before long, tobacco was a lucrative crop in Virginia and North Carolina, and it was exported back to Europe, where it quickly became popular.
In 1964, the U.S. Surgeon General announced that smoking causes cancer and other health problems. The following year, the U.S. became the first country to require health warnings on tobacco products. Cigarette advertising on TV and radio has been banned since 1970.
All cigarette packs now sold in the U.S. have modest warning labels like "Surgeon General's Warning: Smoking Causes Lung Cancer, Heart Disease, Emphysema, and May Complicate Pregnancy."
But 39 other countries have gone beyond such warnings and now require large, graphic depictions of the effects of smoking. In Europe, warning labels feature ghastly photos of blackened teeth and decaying mouths. Uruguay now has one of the world's toughest laws, requiring that health warnings cover 80 percent of cigarette packs.
As warning labels and public-health campaigns in the U.S. and Europe convince many people to quit smoking, tobacco companies have begun to focus on sales in developing countries, which tend to have fewer restrictions, or none at all, on tobacco products.
Studies suggest that pictorial warnings are better at getting the attention of teens than those that feature only text; make smokers more likely to skip the cigarette they had planned to smoke and more likely to quit; and make young people less likely to start smoking.
But health officials say there's some evidence that the most gruesome images, while memorable, are dismissed sooner by smokers.
"Sometimes images that are not as graphic may be more powerful in terms of changing behaviors," says Dr. Lawrence R. Deyton, director of the Food and Drug Administration's Center for Tobacco Products.
The F.D.A. has hired a company to survey 18,000 smokers to determine which labels might be most effective in getting smokers to quit and preventing young people from starting. The results will help winnow the 36 proposed labels down to nine that will actually be used.
By October 2012, manufacturers will be required to include the graphic warnings on all cigarettes sold in the United States.
Tobacco retailers may face challenges displaying the new packaging. Many stores show only the tops of cigarette packs, where the warnings will be shown, so the brands will be obscured.
"When the rule takes effect," says F.D.A. Commissioner Margaret Hamburg, "the health consequences of smoking will be obvious every time someone picks up a pack of cigarettes."
(The New York Times Upfront, Vol. 143, December 13, 2010)