Can there be a legitimate graphical warning for THR products?

With our lab currently working to release some graphical tools for educating about THR, I ran across the proposed Canadian graphical warnings for packages of smokeless tobacco. My immediate thought could not help but be that the proposed warnings I saw are utter scientifically inaccurate nonsense – as long as the government of Canada is lying to people about ST it might as well be claiming that using causes AIDS, hermaphrodism, and rotator cuff injuries.

(For those interested, though it is not the point of this posting, of the four proposed graphics and accompanying text I saw, two were claims that ST causes oral cancer, even though it has been clearly shown that modern Western ST products cause no measurable risk for that disease. One of the two even shows an identifiable individual who got his oral cancer at a young age, which means it was a variant of the disease that is not only clearly not associated with ST use, but not even with the smoking or drinking that cause a substantial risk for oral cancer at age 60 or 70. For various reasons, it has long been suspected that the young cases were infectious in origin and began increasing in incidence in the West as sexual networks became denser, and now there is indeed a widespread belief that HPV is the cause of these and many other oral cancer cases, so this warning practically screams “Canada’s public health policy is to ignore the real causes of cancer and blame it on something that does not really cause it”. One of the other graphics depicts a scary message about “leukoplakia”, a word whose correct meaning does not even imply morbidity, let alone mortality risk, but that has been misused and muddled in so many ways that anyone who actually wants to communicate information stopped using it years ago. The last of them says that ST use causes tooth decay because it contains so much sugar; strangely, no such gross photograph has been proposed for packages of much more sugary items like soda, let alone oranges, so the expressed concern is obviously disingenuous.)

Canada is proposing graphics that are pure, presumably intentional, government-sponsored lies. But that aside, this brings up a question of whether it is possible to provide simplistic warnings about low-risk nicotine products that are useful for promoting health and welfare, or are at least merely honest. This seems difficult enough for text, but doubly tricky for graphics. I am posting my current thoughts about this here, hoping to inspire some thinking and feedback.

To address the challenge, I tried to identify the purposes that graphical warnings serve. The most obvious role of graphics is as pure marketing technique, to circumvent cognitive processes and manipulate people into liking or disliking what you want them to by appealing to base emotion and subconscious triggers. This is clearly what is intended for the graphic warnings on cigarettes in literate cultures. They contain no information that could help someone to make a reasoned decision. Everyone knows that smoking causes lung disease and the picture of a dissected diseased lung adds nothing of use to someone’s understanding of the actual experience of having lung disease. Instead these are just intended to function the same as (in negative counterpart) marketing images that show an attractive woman with a product, triggering a subconscious desire for the product based on our desire to be, have sex with, or otherwise worship pretty people.

A second reason for warning labels is to cut through cacophony. Stepladders, at least in North America, are covered in warning labels about everything from power lines to how they should only be used after taking a training course, and only on flat concrete surfaces that have been checked by a structural engineer, and should be kept away from any tall objects. Ok, I made that up, but you get the idea. The one warning that actually contains useful information that someone might make a mistake about is “do not step on the little tray that flips out on the non-step side that is intended for setting your tools; it is not strong enough to support you”. If this were buried in the dozens of stupid warnings it would be lost, and it is easy to imagine someone making that mistake if not warned. So (at least on one of my ladders) there is a graphical “Don’t Step Here” warning that can rise about the noise.

A third reason, which might be considered a subset of the previous, is to provide a bit of information at a glance, saving people time and effort. In theory, for example, packaged food could be required to have a front label graphic of what common allergens it contained, or a warning about high levels of the bad constituent du jour (fat, sugar, salt, etc.). Finally, graphics can be useful for non-literate populations, like the Mr. Yuck graphic designed to warn pre-literate children that they should absolutely not drink the drain cleaner, no matter how enticing it smells.

The first two of these, and the warning to children, work if you are trying to inform (in the case of the ladder or Mr. Yuck) or trick (in the case of horrifying pictures) someone into absolutely never, under any circumstances, taking the action that you wish them to avoid. The third offers a conditional version of that, helping make sure that someone who is allergic notices that a particular spaghetti sauce is the rare one that contains peanuts. But “absolutely never under any circumstances” – the only message graphical warnings seem particularly suited for – is clearly the wrong message to put on a low-risk alternative to smoking.

Of course, there are compelling arguments that a government of and for the people should not manipulate people regarding smoking either, and instead should limit itself to educating them and letting them make their own decisions. But even if you think the diseased lung graphic is perfectly legitimate because smoking is so harmful, there is still no basis for extrapolating this to ST and similar products. Using low-risk nicotine products causes health risks that are of similar magnitude to using any of countless consumer products; those products often (but not always) have warnings, but none of them are meant to communicate “never ever use this, no matter how much you like it.” Imagine the government demanding that manufacturers put horrifying graphical warnings on unhealthy foods, sporting equipment, or cars.

Even for observers who accept only the weakest form of THR – that nicotine really is different from other choices and everyone should be pushed hard to quit, but those who “cannot” quit should be encouraged to use low-risk products instead of smoking – how exactly is a graphic supposed to work? How do you draw a picture of “do not use this at all ever, unless you happen to already smoke, in which case please use this instead”?

Graphic warnings work perfectly for anti-tobacco activists who are not really trying to improve public health and do not want to promote informed rational welfare-maximizing behavior. For the anti-tobacco extremists, scaring people away from low-risk nicotine products is critical because once people are aware of the low risk, many are not going to want to pursue abstinence. Thus, the misleading Canadian labels work for them because they encourage people to continue to smoke, and the resulting high heath risks maintain the incentive to quit. It is not surprising that this is Canada’s choice, given the lack of measured and rational tobacco policy. After all, they have raised taxes so high that almost half of cigarette sales are black market (and are proud of having done so), and the authoritarian government action has been used to kill all hope for THR by blocking the markets for both snus and e-cigarettes. But what if a miracle occurred and they decided they actually wanted to promote public health (i.e., THR), or to merely be honest, but remained committed to using graphical warnings? Is this combination even possible?

The best warning to put on a package of ST is a warning against smoking and that this is a safer choice. That is the message our new graphical tools try to make clear. But I am guessing that this will not fulfil the demand for a warning about the product in hand. The statement, “This product is addictive” is likely to appear (it is so ill-defined as to be pretty much meaningless, but at least means that it is not blatantly false). But a graphic of addiction? The image of a homeless crack user breaking into a car because he is desperate for money for a score would nicely illustrate how plastic the word “addiction” is, but would tell us little about ST. You could draw someone suffering from his addiction, stuck in an office or in transit, desperate to get outside to light… – oh, wait, that is not a problem with smokeless products.

It is difficult to envision a graphic that illustrates a sphygmomanometer showing a slight increase in mm of Hg, though acute increase in blood pressure is an unhealthy outcome that is clearly caused by smoke-free nicotine products. A notation that this product is not for children is possible, and might qualify as a warning. Oral cancer is the favorite claim and lends itself to manipulative marketing quite nicely, but come on people, get with the decade! – no anti-THR activists who seek to retain a pretense of expertise and honesty still claims that Western products cause measurable risk. Would it be good enough to show a person not being able to score a kiss because their companion does not care for the taste?

So there is the problem. Any thoughts?

-Carl V. Phillips