Content warning

Despite being the country that first launched the practice of labeling nicotine and tobacco products, which are some of the most addictive and deadly substances available today, the United States now lags behind its peers in communicating the danger.

And these products are deadly, as warning labels on cigarettes and cigars in more than 130 countries indicate. Some labels in Canada have displayed photos of a diseased heart or a blackened lung. In Brazil, a gangrenous foot with missing toes. In the European Union, a sick newborn exposed to cigarettes in utero. In India, a mouth with missing teeth or tumors. And in Australia, which has some of the toughest laws for tobacco warnings in the world, labels that cover most of a cigarette pack have shown pictures of esophageal cancer, damaged and missing teeth, and the anatomy of an eye blinded by macular degeneration.

Research by Gillings School faculty has demonstrated that warning labels are practical, efficient and powerful tools that public health officials use to help consumers make smarter choices about the products they consume.

“The warning is right there on the package. So people see it every time they decide to buy and use the product.”

– Marissa Hall

Labels are effective because they are more than a means of communication. They are also an intervention – an action taken to improve a situation. They have the potential to work precisely when a person makes a choice that can impact their health.

“The warning is right there on the package. So people see it every time they decide to buy and use the product,” said Marissa Hall, PhD, assistant professor of health behavior at the Gillings School. “It’s fundamentally different from social media or health campaigns. Those are in the ether, but they don’t deliver the cue to action right as a person acts.”

The U.S. led the evolution of warning labels on tobacco products dating back to the 1960s, helping to refine side-of-pack labels and create more impactful messages that, by the 1980s, warned of heart disease, emphysema, pregnancy complications and carbon monoxide and encouraged quitting to improve health. They also labeled smokeless tobacco products with warnings about addiction, mouth cancer and gum disease.

Since that time, progress to improve the effectiveness of tobacco labels has stalled in the U.S., due in large part to mounting lawsuits from cigarette manufacturers. Even so, public health’s efforts to research and design more impactful warning labels have grown.

Researchers at the Gillings School and the UNC Lineberger Comprehensive Cancer Center have studied the effects of pictoral warning labels on cigarettes for decades. Their published research has been a boon to policy experts at the U.S. Food and Drug Administration (FDA) as they continue to develop recommendations that improve health for Americans. Those researchers include Hall, Kurt Ribisl, PhD, chair and Jo Anne Earp Distinguished Professor of health behavior, Noel Brewer, PhD, Gillings Distinguished Professor in Public Health, and Seth Noar, PhD, James Howard and Hallie McLean Parker Distinguished Professor at the UNC Hussman School of Journalism and Media.

Researchers at the Gillings School and the UNC Lineberger Comprehensive Cancer Center have studied the effects of pictorial warning labels on cigarettes for decades.

Their studies, which included the first meta-analysis (a study of all published experimental studies) on graphic warning labels and a randomized controlled trial on graphic warning labels, helped build high-quality evidence the FDA needed to design effective warning label regulations that could reduce rates of smoking and withstand continuous litigation from the tobacco industry.

“We have a whole chain of evidence, from exposure to behavior, showing that these warning labels do work,” said Noar.

Outside of the U.S., countries across the globe have been so successful at implementing graphic warning labels that the warnings have now become a standard recommendation for the World Health Organization and are a critical part of their MPOWER measures for tobacco control.

In 2009, the U.S. Congress passed a law giving the FDA authority to regulate tobacco products, and the FDA finalized regulations in 2020 to put graphic warning labels on cigarettes. That same year, a study found that nearly 70% of Americans support these pictorial warning labels.

So why are these pictorial warning labels, which are broadly supported by Americans to help them make better health choices, still not on cigarette packs? In large part because of pushback in the form of lawsuits, political pressure and public comment from tobacco industries that claim a Constitutional right not to put the labels on their products.

Hall sees this sort of industry pushback play out in label regulations for other products, as well, including sugary drinks, junk food and alcohol.

Her work with Lindsey Smith Taillie, PhD, associate professor of nutrition at the Gillings School, used their own UNC Mini Mart to find that pictorial warning labels, such as ones that show a damaged heart or a foot affected by gangrene from Type 2 diabetes, on sugary drinks made North Carolina parents 17% less likely to purchase them for their children.

Smith Taillie and Barry Popkin, PhD, W. R. Kenan Jr. Distinguished Professor of nutrition, have also been collaborating to evaluate the effectiveness of front-of-package warning labels on sugar-sweetened beverages and ultraprocessed foods in Chile, both of which have led to decreases in the purchase of unhealthy products.

Experts find these data are valuable in the design of public health regulations and warning labels that inform the public about the health risks of consuming these products. But industries, which see the decrease in purchases as a threat to their bottom line, often fight back through the courts and through public commenting to regulatory agencies.

Experts sometimes refer to this process as the scream test.

Experts sometimes refer to this process as the “scream test” – the louder an industry “screams,” or fights against a regulation, the more likely the regulation is to be effective at improving public health.

“Every time FDA has public comments on these warning labels, they’re flooded with comments, 10-to-1 industry to public health researchers,” Hall said. “Industry representatives write public comments that are really negative, and then agencies see it as an overwhelming negative response.”

Despite the push back, Hall and colleagues are continuing their warning label research and seeing incremental progress in the U.S. and abroad. In late 2024, the U.S. Supreme Court refused to strike down the FDA’s new pictorial warning label guidelines, although the implementation date was temporarily postponed by a ruling in early 2025 from the U.S. District Court for the Eastern District of Texas. In early 2025, the FDA also entered a public comment period for a proposed new front-of-package nutrition label.

Hall and collaborators are now setting their sights on alcohol, which carries many health harms, including an increased risk of cancer. In early 2025, former U.S. Surgeon General Vivek Murthy (and Gillings School commencement speaker in 2024) called for warning labels on alcohol to be updated to inform the public about these risks. Hall says that very few countries warn about this link. The U.S. warning label on alcohol, which hasn’t been updated since 1988, only warns about the harms of drinking alcohol during pregnancy or impairing the ability to drive or operate machinery.

“The increased recognition of the risks of alcohol, including cancer risks, could lead to a new phase in alcohol warning label policy,” she said.

Labels are a part of a larger public health strategy to reduce the purchase and consumption of products that are harmful to health, but Hall says they’re not a panacea. The behavior change effects can be small, but when they are extrapolated across a population, they can be very meaningful. They work in tandem with policies that regulate the placement and advertising of these products in stores and in the media, as well as taxes on their purchase.

Even if a warning label doesn’t prevent you from making a purchase, it might make you think twice before you consume it. So next time you’re at the store, take a moment to check the product label. It’s an opportunity to empower your public health knowledge and make a choice that’s better for your health.