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Cigarette packs are being stripped of advertising around the world. But not in the US.

Cigarette packs have long served as portable advertising for tobacco companies, with smokers conveniently disseminating branding and imagery wherever they go.

Packaging has also long been a central target for health advocates in the global effort to get more people off deadly tobacco products.

This week, the World Health Organization called on countries everywhere to step up the war on tobacco advertising and promotion by introducing plain, or standardized, packaging of tobacco products.

"Plain packaging reduces the attractiveness of tobacco products," said WHO Director-General Margaret Chan. "It kills the glamour, which is appropriate for a product that kills people."

Before and after photos of cigarette packs from Australia, where plain packaging was introduced in 2012.
David Hammond

In 2012, Australia became the first country in the world to introduce the measure. Tobacco companies there are now restricted in their use of logos, colors, and brand images, and instead have to use a standard (unsavory green) color and plain font. The boxes also prominently feature warnings about the harms of smoking, including nasty images that show what cigarettes can do to the body.

Others countries — France, the United Kingdom, and Ireland — are now following Australia's lead, implementing plain packaging regulations of their own. Norway, Hungary, Slovenia, Sweden, Finland, Canada, New Zealand, Singapore, Belgium, and South Africa are all formally considering similar measures.

Notably, the United States isn't even close to getting plain packaging on cigarettes anytime soon. We'll get to why we're lagging on this front, and why we really shouldn't be, below. But first, here's why plain packaging makes sense for public health.

Plain packaging works — but not necessarily by helping people quit

More before and after photos of cigarette packs from Australia, where plain packaging was introduced in 2012.
David Hammond

Smoking is the leading cause of preventable death globally, killing about 6 million people every year. Tobacco marketing is considered a massive driver of cigarette use — which is why the industry shells out tens of billions every year pushing its products to consumers. Cigarette companies also mislead consumers about the relative harms of certain types of cigarettes through the use of colors (light colors appear to imply a product is safer) and language (think "light," "organic," or "low tar").

To counteract those marketing efforts, governments started requiring gruesome pictures of the health effects of cigarettes on packs in 2000. (These have more of an impact than text-only warnings.)

Plain packaging came next, with Australia introducing the world's first regulations in 2012. According to the Framework Convention on Tobacco Control, a global health treaty aimed at reducing the use of tobacco products, plain cigarette packs have three public health benefits: They make tobacco products less appealing, they make health warnings more prominent, and they limit tobacco companies' use of design to mislead consumers.

There's good evidence to back this up. A number of systematic reviews of the research have come to pretty consistent conclusions that plain packaging works. As this 2015 review summed up:

Studies deploying a range of methodologies, including observational and experimental research, consistently show that plain packaging can reduce the appeal of cigarettes, decrease the power of the cigarette pack as a marketing vehicle, increase attention to the health warning labels, and impact smoking-related attitudes and cognition.

There's also strong evidence from Australia, now four years into its plain packaging effort, that the measure has had an impact on smoking habits. The government commissioned a review of the impact of the packaging changes and found that smoking rates fell an additional 0.55 percentage points between December 2012 and September 2015 — a drop that it attributed to the packaging changes only (and not the other anti-tobacco policies the country implemented around that time).

"This equates to more than 108,000 people quitting, not relapsing or not starting to smoke during that period," the WHO pointed out. That's a big public health win.

But as University of Waterloo tobacco control policy expert David Hammond noted, these policies aren't necessarily aimed at making people quit. They're more about prevention: reducing the number of people who start smoking and protecting young people from tobacco marketing. "The expectation is that the benefit will accrue and grow over time as children grow up without the positive brand imagery on packages," Hammond said.

Either way, they seem to be helping. And according to University of Stirling tobacco packaging researcher Crawford Moodie, that should be no surprise: "The findings [on the benefits of plain packaging] are also consistent with idea that packaging is an important vehicle for marketing, as is clear from the tobacco industry’s own internal documents." Indeed, tobacco industry communications were made public through legislation and shed light on how the industry hooks consumers.

"If you look at what tobacco companies say," Moodie added, "it paints quite a powerful image of the packaging."

When countries try to restrict packaging, tobacco companies fight back

Unsurprisingly, just about every time a country even so much suggests it's going to introduce plain packaging on cigarettes, tobacco companies threaten lawsuits. Typically, they dispute the packaging restrictions on the grounds that they violate international trade and trademark laws and their right to free speech.

Governments have so far managed to win most of these cases.

The Australian government has faced three separate challenges and won two (with a third decision still pending). In one particularly bold effort, Philip Morris International transferred ownership of its Australian operation to Hong Kong in order to fight the plain packaging mandate there by exploiting the provisions in a bilateral trade agreement between Hong Kong and Australia. It lost.

Last week, tobacco companies in the UK tried to stop plain packaging efforts there, but also lost. The ruling said plain packaging may infringe a company's right to free speech on the package — but that that's justified on health grounds in the public interest.

"[These lawsuits] are meant to be a deterrent to other jurisdictions," said Hammond. "They require a huge amount of resources to fight."

The US hasn't updated the health warnings on packs in 31 years

cigarette pack US Mike Focus/Shutterstock

The warnings on US packs are a lot more subtle.

Compared with most other Western nations, the US has been sluggish to rein in the advertising on cigarette packs. Efforts to update warnings have mostly stalled or failed, and as a result US cigarette packs haven't changed much since the 1980s.

Why? Typically the First Amendment argument is invoked: Protections on free speech here are so strong that public health officials don't stand a chance, the thinking goes.

But according to Hammond, "Protection of free speech in the US is not unique." The UK has it, too, but also managed to implement plain packaging measures after tobacco companies (including British American Tobacco, Philip Morris International, Japan Tobacco International, and Imperial Brands) challenged the law, taking the case up to the UK High Court. (The court rejected the challenge.)

According to Kenneth Michael Cummings, co-leader of the Medical University of South Carolina's tobacco research program, in the US "it’s all about the lobbying." He added: "We have the best Congress money can buy."

The powerful tobacco lobby in the US has managed to delay federal regulation of the industry for decades. The Food and Drug Administration only gained authority over the tobacco industry in 2009 with the Family Smoking Prevention and Tobacco Control Act.

What's more, there are 180 countries that have ratified the UN's Framework Convention on Tobacco Control, which commits countries to require graphic warnings on packs and other anti-smoking regulations. The US isn't one of them, which "means the US isn’t obligated to do what other countries have done," Cummings said.

Dozens of countries in Latin America and Asia have already implemented five rounds of pictorial health warnings on packaging over the past decade, but packaging in the US hasn't changed much since 1985. A text-only surgeon's general warning was introduced in 1966, but it hasn't been updated in 31 years.

"The lack of movement on packaging in the US is consistent with a lot of other areas [in tobacco control]," Hammond said. "The US probably falls below third-world countries in terms of some of the tobacco control policies related to labeling."

FDA spokesperson Michael Felberbaum told Vox that the agency has added some packaging restrictions on tobacco products in recent years, including prohibiting the use of descriptors such as "light," "low," or "mild." In 2016, FDA also began asking companies to warn smokers that "nicotine is an addictive chemical" — but that statement won't appear on all packaging until mid-2018.

But attempts to go any further have so far flopped. In 2011, the FDA published a rule that required companies to use new text and graphic images on packs — but that was challenged in court by several tobacco companies. The FDA is now working to come up with alternatives that are consistent with what the tobacco statute says and the court has ruled. Plain packaging, however, is not yet part of that conversation.

The next frontier: uglier packaging inserts and cigarettes

The future: cigarettes that carry warnings on them, plus inserts about quitting.
Crawford Moodie

In the future, public health researchers around the world are already thinking about how to make more elements of a cigarette package unappealing — including the interior and the cigarettes themselves.

Moodie discussed the idea of inserts in tobacco packages that contain information about quitting and the benefits of doing so, and the possibility of uglier cigarettes with unattractive designs and health warnings written right on them.

He's not holding his breath for all those changes. The first visual warnings were introduced on cigarette packs in Canada in 2000. It's taken nearly 20 years to get widespread adoption. If plain packaging follows that same timeline, it'll be about 2030 by the time a significant number of countries introduce regulations. Considering we've known for about half a century that cigarettes can kill people, that's (darkly) comically slow. And in the US, even more so.