The More Fear, the More Effect? Is There any Threshold Limit for Labelling Cigarette Packs?


Fatemeh Kokabisaghi 1 , 2 , *

1 Healthcare and Law Department, Institute of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands

2 Department of Management Sciences and Health Economics, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran

How to Cite: Kokabisaghi F. The More Fear, the More Effect? Is There any Threshold Limit for Labelling Cigarette Packs?, Health Scope. 2018 ; 7(2):e80383. doi: 10.5812/jhealthscope.80383.


Health Scope: 7 (2); e80383
Published Online: May 27, 2018
Article Type: Editorial
Received: October 12, 2016
Revised: April 5, 2017
Accepted: July 26, 2017
Copyright © 2018, Journal of Health Scope. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License ( which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited

In the framework convention on tobacco control (FCTC), world health organization (WHO) adopted a range of tobacco control policies including labelling tobacco packages with health warnings. Now, 180 countries are parties of this treaty and committed to implement it (1). Through years of implementation of this treaty, text and graphic messages, which are applied on the packages, are getting repetitive. Thus, states have been searching for more powerful ones to intensify the health threats of smoking. This is probably due to the fact that they believe that the more fear, the more effect.

Fear appeal is often used to discourage people from having unsafe sexual practices, alcohol abuse, reckless driving, as well as smoking cigarettes. It creates anxiety and tension, which motive people to seek ways to reduce these feelings (2). Many studies indicated that in some circumstances, fear appeals could influence intentions and lead to a desired change of behavior (3, 4). However, the converse is as equally or even more likely to apply (5, 6). Recently the Netherlands has introduced a new label with an image of a young dead man in a shroud for cigarette packs. These kinds of labels have been criticized for causing unnecessary and excessive emotional distress to smokers, especially vulnerable ones. Examples are individuals who are not socially or mentally ready to quit smoking such as old people with chronic diseases, illegal immigrants who do not have access to efficient cessation facilities, and hard core smokers who might not be able to quit smoking (2, 7). Long-term exposure to repeated fear messages causes chronic heightened anxiety and endangers the physical and mental health of people (7). It is not ethical to create excessive anxiety to change an individuals behavior. According to the universal declaration of human rights, people have a right to be free from fear, as well as, a right to be free from interference in one’s practices, if their practices do not harm others. Therefore, everyone has a right to determine his/her life style and behavioral patterns (8). An adult, who knows tobacco use is harmful to his/her health, has the right to choose smoking. Respect to human rights and dignity of smokers should be the corner stone of anti-smoking policies. States are supposed to give information about the health risks of smoking and promoting a healthier life style, not to frighten people. Moreover, repeating a message, while people already know it, and many smokers are willing to quit smoking, does have little value. Searching for more powerful messages is fruitless too (9). What can be scarier than a picture of a young dead person? Moreover, use of fear appeals for labelling cigarette packs seems contradictory. Labels frighten smokers in order to push them to stop smoking and inside the packs, there is something addictive that makes smokers smoke more. It seems that more efforts should be done to make cigarettes less addictive.

Another important fact that seems to be ignored about labelling cigarettes with scary graphic images is that these messages are seen by significant individuals other than the intended receives such as the children of smokers. Children should be protected not just against second hand smoking, but also against unintentional fear appeal of cigarette packs’ labels. Smokers get these messages and carry them to wherever they go, including their houses. These labels might cause intense sadness and anxiety to the family members and friends of the smokers. Labels of products play the role of media and should be sensible to the effects on and responses of audiences. Due to these effects, moderate and low levels of tension should be considered. Furthermore, ethical guidelines should be adopted about labelling cigarette packs and the messages should be tested before applying on the packs. Besides, they can be placed inside the packages, not on them. Furthermore, the messages on the labels are kinds of health education and should be designed based on the mental, cognitive, and social capabilities of the target population. When they are planned to target a wide range of population of different ages and social and economic situations, they should be designed in the way to be appropriate for everyone. In addition, health education is a health service and providing every health services needs the consent of the target, particularly in the case of using fear appeals. It is an exaggerated point of view about cigarette labels. However, people do not have an opportunity to not get them. It does not seem to be ethical to expose unwilling audiences to this advertisement. People are able to turn off the TV when it shows an unpleasant advertisement, but what can they do to prevent seeing these images on their cigarette packs? On one hand, the validity of such graphic messages is questionable. Do all the smokers die from the effects of smoking at a young age? These graphic warnings might cause reactance or increase in consumption. Smokers may avoid them (2, 7); therefore, health promotion programs lose these groups.

The final point is that positive emotions such as empathy, love, and hope can be used to encourage good behavior (7). Bandura believes that “public health messages that elicit positive emotions make people feel more efficacious and optimistic about the benefits of new healthful practices than do messages that arouse fear” (10). A study showed that strength of emotional appeal has been high for cigarette packs, which portray family love or attachment (11). Instead of the photo of a dead man, there can be a photo of a healthy man enjoying life with his family. If the message is about empowering people and convincing them about the benefits of quitting smoking, people will be encouraged not only to quit smoking but to also have a healthy life style (9). Finally, it is important to support smokers to quit smoking. These all indicate that some of the current graphic images seem to be exceeding the requirements of the tobacco framework. The governments and WHO should be better friends with smokers and do not harm them.


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