Objectives. We quantified the pattern and passage rate of cigarette package health warning labels (HWLs), including the effect of the Framework Convention on Tobacco Control (FCTC) and HWLs voluntarily implemented by tobacco companies.

Methods. We used transition probability matrices to describe the pattern of HWL passage and change rate in 4 periods. We used event history analysis to estimate the effect of the FCTC on adoption and to compare that effect between countries with voluntary and mandatory HWLs.

Results. The number of HWLs passed during each period accelerated, from a transition rate among countries that changed from 2.42 per year in 1965–1977 to 6.71 in 1977–1984, 8.42 in 1984–2003, and 22.33 in 2003–2012. The FCTC significantly accelerated passage of FCTC-compliant HWLs for countries with initially mandatory policies with a hazard of 1.27 per year (95% confidence interval = 1.11, 1.45), but only marginally increased the hazard for countries that had an industry voluntary HWL of 1.68 per year (95% confidence interval = 0.95, 2.97).

Conclusions. Passage of HWLs is accelerating, and the FCTC is associated with further acceleration. Industry voluntary HWLs slowed mandated HWLs.

The United States implemented the first cigarette package health warning label (HWL) in 1966 with the weak message, “Cigarette smoking may be hazardous to your health” on the side of the pack. By 2012, 209 countries and territories had implemented HWLs, ranging from weak text messages on the side of the pack to strong graphic warning labels (GWLs) on the pack front.1 Experimental and epidemiological data suggest that HWLs, especially GWLs, are important tools in tobacco control.2 Indeed, there is some evidence that GWLs enhance relevance and perceived effectiveness of tobacco control messages for individuals in disadvantaged groups3 and smokers cite GWLs as an impetus for quitting.4 Fong et al. prepared an extensive review of GWL literature that was published in 2009 concluding that GWLs have been an effective tobacco control intervention in numerous countries worldwide and may reduce disparities in knowledge for tobacco-related harms in countries with low literacy.5

The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) is a public health treaty designed to address issues of tobacco control. Article 11 of the treaty commits parties to implement large (at least 30% of the front surface area of the pack) rotating labels that may include graphics that may disrupt the impact of brand imagery on packaging and decrease the overall attractiveness of the package.6,7

By applying transition probability matrices and event history analysis, we quantified the effects of voluntary industry regulation on the underlying process of implementation of HWLs. Understanding how voluntary regulation impedes adoption may help explain why some countries never adopt mandatory HWLs and health policies more generally. Indeed, voluntary regulations have been used to preempt regulation in other health-related areas8 including food advertising and labeling regulation.9 This is particularly important in public health as many industries use voluntary regulation to preempt or delay the regulatory process.

There has been some research quantifying the effect of the tobacco industry and the FCTC on smoke-free policies. There is some evidence that being connected to GLOBALink (a tobacco control online community) increased the likelihood of ratifying the FCTC.10 Furthermore, there was a positive effect of the FCTC on strength and presence of tobacco control policies in individual countries.11

In examining the implementation of HWLs, it is important to consider tobacco companies’ attempts to hamper this process.1 One way that tobacco companies seek to block or delay tobacco control policies is by implementing ineffective voluntary regulation to displace advertising restrictions12,13 and smoke-free policies,14 avoid taxation,12,15 and delay the FCTC itself.16 Health warning labels were no different. Between 1992 and 2012, 16 countries made voluntary agreements with the tobacco industry to put weak HWLs on cigarette packages, and in 1992 Philip Morris unilaterally put English-language HWLs on the sides of packages being sold in 49 small, mostly African, countries whose native languages were not English.1,17 British American Tobacco followed the same practice soon after. To date, no one has quantified the effect of these voluntary HWLs (whether by voluntary agreement or unilateral) on the rate of adoption of stronger HWLs.

We describe the process of adopting HWLs over time beginning with the first mandated warning labels in the United States in 1966. We also tested whether the FCTC affected adoption of HWLs and quantified the effect of voluntary industry HWLs on the adoption of strong HWLs.

We collected information on HWLs from WHO reports on the tobacco epidemic from 2008, 2009, and 20117,18,19; the Canadian Cancer Society Cigarette Package Health Warnings International Status Report 201220,21; and tobacco industry documents available at the University of California San Francisco Legacy Tobacco Documents Library (http://legacy.library.ucsf.edu). Information included the nature and date of implementation of each HWL. We collected data from 1965 (the year before the first HWL in the United States) through October 2012. An HWL was considered FCTC-compliant if it was rotating and covered at least 30% of the frontal surface. We analyzed current United Nations member states because they represent the vast majority of rule-making entities and clearly have the legal power to mandate HWLs.

Extending previous work on HWLs,1 we scored government-mandated HWLs on a 6-level ordinal scale, from vague text HWLs on the side of the cigarette packages (the original US HWL) to strong graphic HWLs on the front of the packages (Table 1). We also identified countries that initially had voluntary industry HWLs (the 16 countries with voluntary agreements between the tobacco industry and government and the 51 countries where tobacco companies unilaterally implemented HWLs). The event history analysis did not allow for backsliding from mandated to voluntary industry HWLs. Therefore, we dropped the Philippines, Hungary, Japan, Uganda, Azerbaijan, the Bahamas, and Iceland from the event history analysis because the data from these countries included a transition from a stronger HWL to a weaker HWL or to no HWL.

Table

TABLE 1— Ordinal Scale for Health Warning Labels on Cigarette Packages

TABLE 1— Ordinal Scale for Health Warning Labels on Cigarette Packages

HWL Score (Year of First Usage) HWL DescriptionFirst Implemented Example (Country, Year)
1: Vague HWL (1966)Government requirement and vague warning health message on the side of the pack“Caution: cigarette smoking may be hazardous to your health” (United States, 1966)
2: Definite HWL (1969)Smoking established as a definite health hazard or specific diseases mentioned, message on the side of the pack“Warning: cigarette smoking can cause lung cancer and heart diseases [on cellophane]” (Iceland, 1969–1971)
3: Front HWL (1987)Affirmative health message on either or both the front or back of the pack“Smoking is a main cause of cancer, diseases of the lung, and diseases of the heart and the arteries” (Saudi Arabia, 1987)
4: Rotating HWL (1977)Rotating detailed health messages on the front of pack“Smokers run an increased risk of heart attacks and certain diseases of the arteries. National Board of Health and Welfare [1 of 16 HWLs]” (Sweden, 1977)
5: FCTC-compliant HWLs (1996)Rotating detailed health messages on the front and back of pack covering at least 30% of the pack (minimum FCTC requirement)1Front or back: “Attention! The link between smoking and lung diseases has been scientifically proven. Minister of Health and Social Welfare”
Front or back: “Smoking or health—The choice is yours. Minister of Health and Social Welfare [2 of 4 HWLs]” (Poland, 1996)
6: GWL (1985)Graphic health warnings: pictures to reinforce the health message on either or both the front or back of the packEight cartoon graphic HWLs with images such as a pair of black lungs, a patient in bed, or a diseased heart (Iceland, 1985–1996)

Note. FCTC = Framework Convention on Tobacco Control; GWL = graphic warning label; HWL = health warning label. We used World Health Organization reports from 2008, 2009, and 20117,18,19 to confirm both FCTC-compliant HWLs and GWLs and the Canadian Cancer Society Cigarette Package Health Warnings International Status Report 20122 to confirm GWLs. With regard to FCTC compliancy we paid attention to both size and rotation of HWLs. We used FCTC implementation reports21 to fill in some data points between 2003 and 2007 on FCTC compliance. We assumed that no major changes took place in HWL policies between 1999 (our last data point in the tobacco industry documents) and the times reported in the FCTC implementation reports. We assumed that all countries with GWL were FCTC-compliant.

Source. Hiilamo et al. 1

Two observers coded the HWLs. Intercoder reliability with an ordinal Krippendorff α was .99 (computed with the R concord package kripp.alpha command, updated March 25, 2011; available at http://rss.acs.unt.edu/Rdoc/library/irr/html/kripp.alpha.html).

Transition Probability Analysis

This analysis describes the sequence of HWLs and the pace of transition from one type of HWL (including voluntary industry HWL) to the next. We calculated the probability of transitioning to an HWL at the end of the time period on the basis of the country’s HWL status at the beginning of the time period. Specifically, we computed the number of countries in which a particular HWL transitioned to a different HWL during each time period, which produced a count for each type of transition. We then converted these counts to transition probabilities by dividing by the total number of transitions that occurred.

To investigate whether the pattern and adoption rate of HWLs has changed over time, we defined 4 time periods. The first period, 1965 through 1977, lasted from the time of the first (US) HWL (score 1) to the first rotating detailed health messages on the front of the pack (score 4). The second period, 1977 through 1984, ended with the first GWL in Iceland. The third period, 1984 through 2003, ended with the first opportunity to sign the FCTC. (We selected the first opportunity to sign the FCTC, 2003, rather than FCTC ratification, 2005, because the topic of the FCTC itself, including discussions to sign, may have influenced HWL implementation.) The fourth period, 2003 through 2012, extended through the final year in our sample.

To avoid losing any data, we took the same year that ended each period as the first year of the subsequent period. Countries with no transition were not included in the transition probability analysis. These countries are represented in the diagonal elements of Table 2 and discussed separately in the Results section.We used the Multi-State Markov package (updated September 10, 2011; available at http://rss.acs.unt.edu/Rdoc/library/msm/html/msm.html) in R for the calculation of transition matrices.

Table

TABLE 2— Probability of Change From One Category of Health Warning Label to Another Among Countries That Changed Health Warning Labels on Cigarette Packages

TABLE 2— Probability of Change From One Category of Health Warning Label to Another Among Countries That Changed Health Warning Labels on Cigarette Packages

HWL Following Change
No HWLVol HWLVague HWLDefinite HWLFront HWLRotating HWLFCTC HWLGWL
1965–1977 (average no. of changes/y = 2.42)
HWL preceding change
 No HWL164a4 (0.14)10 (0.34)12 (0.41)01 (0.03)00
 Vol HWL00a000000
 Vague HWL000a1 (0.03)0000
 Definite HWL1 (0.03)000a0000
 Front HWL00000a000
 Rotating HWL000000a00
 FCTC HWL0000000a0
 GWL00000000a
1977–1984 (average no. of changes/y = 6.71)
HWL preceding change
 No HWL129a3 (0.06)14 (0.30)020 (0.43)1 (0.02)00
 Vol HWL03a01 (0.02)01 (0.02)00
 Vague HWL007a6 (0.13)0000
 Definite HWL01 (0.02)012a0000
 Front HWL00000a000
 Rotating HWL000001a00
 FCTC HWL0000000a0
 GWL00000000a
1984–2003 (average no. of changes/y = 8.42)
HWL preceding change
 No HWL28a60 (0.38)16 (0.10)22 (0.14)1 (0.01)5 (0.03)01 (0.01)
 Vol HWL05a4 (0.03)2 (0.01)1 (0.01)2 (0.01)00
 Vague HWL1 (0.01)1 (0.01)1a13 (0.08)07 (0.04)00
 Definite HWL2 (0.01)2 (0.01)023a3 (0.02)12 (0.08)1 (0.01)0
 Front HWL00003a1 (0.01)00
 Rotating HWL000002a02 (0.01)
 FCTC HWL0000000a0
 GWL000001 (0.01)00a
2003–2012 (average no. of changes/y = 22.33)
HWL preceding change
 No HWL6a05 (0.03)2 (0.01)1 (0.01)2 (0.01)10 (0.05)2 (0.01)
 Vol HWL026a13 (0.07)6 (0.03)5 (0.03)1 (0.01)6 (0.03)0
 Vague HWL005a2 (0.01)4 (0.02)1 (0.00)6 (0.03)2 (0.01)
 Definite HWL0006a21 (0.11)6 (0.03)15 (0.08)14 (0.07)
 Front HWL00000a5 (0.03)14 (0.07)7 (0.04)
 Rotating HWL1 (0.01)00000a28 (0.14)8 (0.04)
 FCTC HWL0000002a13 (0.07)
 GWL00000000a

Note. FCTC = Framework Convention on Tobacco Control; GWL = graphic warning label; HWL = health warning label; Vol HWL = voluntary tobacco industry health warning label. Numbers in parentheses are the probability that countries that made each transition. Numbers outside the parentheses are the raw counts of countries that made each transition. Vague HWL = score 1; definite HWL = score 2; front HWL = score 3; rotating HWL = score 4; FCTC-compliant HWL = score 5; and GWL = score 6.

aCountries with no HWL status transition are not included in the transition probability analysis.

Event History Analysis

We used Cox proportional hazard models in 3 event history analyses to quantify predictors of 3 HWL events: (1) mandated rotating HWLs that do not occupy 30% of a pack (score 4), (2) FCTC-compliant HWLs rotating on the front cover and back that occupy at least 30% of front surface area of a pack (score 5), and GWLs (score 6). We stratified the analyses on whether the first HWL was required by law (n = 124 countries) or voluntarily instituted through agreement between a government and the tobacco industry or unilaterally by the industry (n = 65 countries; as noted previously, some countries were eliminated from the analysis because they went from mandatory to voluntary HWLs).

The independent variables were time (years) since ratification of the FCTC (0 for countries that did not ratify the FCTC), time since first mandated HWL (0 for the absence of a mandated HWL), and strength of first mandated HWL (scored 1–5; Table 1; 0 for no mandated HWL). As of February 2013, the following WHO members had not ratified the FCTC: Argentina, Cuba, El Salvador, Ethiopia, Haiti, Morocco, Mozambique, Switzerland, and United States. For the 124 countries that began with a mandated HWL, we included 5 categorical variables to represent the 6 WHO regions, with Europe as the reference region. For the 68 countries that began with a voluntary industry HWL, only 18 countries in the strata that started with voluntary industry HWLs implemented FCTC-compliant HWLs and only 7 implemented GWLs. Therefore, the WHO region categorical variables could not be included to avoid having an overspecified model. We included countries with no HWL in the analysis of 126 countries with mandated HWLs.

We used the STSET commands in Stata IC version 12 (StataCorp LP, College Station, TX) for the event history analysis.

The trajectory of HWL passage was almost always from weaker HWL to stronger HWL (Table 2). However, there were a number of exceptions. For example, Iceland went from having definite HWL (score 2) in 1969 to no HWL in 1972 (score 0) and then to a rotating HWL (score 4) in 1985. Japan went from having a required HWL in 1972 (score 0) to a voluntary HWL and back to a required HWL in 2008 (score 5).

The diagonal elements in Table 2 shows the number of countries that did not change HWL status during each of the 4 time periods. Between 1965 and 1977, only 27 countries adopted HWLs (including 4 that adopted voluntary industry HWL), leaving 164 countries without any HWL. Between 1977 and 1984, the number of countries with no HWL dropped to 129 countries through a combination of countries with HWL moving to stronger HWL and countries introducing new HWL. Over time, the number of countries without an HWL decreased to only 6 by 2012. The rate of transition increased; when we excluded countries that had already reached FCTC-compliant rotating HWLs or GWLs, 164 countries did not transition from one type of HWL to another in 1965–1977, 152 in 1977–1984, 62 in 1984–2003, and 45 in 2003–2012. (Twenty-six of these countries had voluntary industry HWLs.)

Among the countries that changed their HWLs during each period, the number of HWLs passed during each time period accelerated, from a transition rate of 2.42 per year in 1965–1977 to 6.71 per year in 1977–1984, 8.42 per year in 1984–2003, and 22.33 per year in 2003–2012. The median number of steps within HWL transitions remained stable across the 4 periods (1965–1977: median = 1; interquartile range [IQR] = 1–2; 1977–1984: median = 3; IQR = 1–3; 1984–2003: median = 1; IQR = 1–2; 2003–2012: median = 2; IQR = 1–3). The pattern of change in HWLs varied across time periods. During the first 2 periods (1965–1977 and 1978–1984) the most common transitions were from an absence of mandated HWLs to messages depicting smoking as a vague health hazard and definite health hazard (“vague HWL” and “definite HWL”). During the third period (1984–2003), most countries without an existing HWL implemented some type of HWL or had a voluntary industry HWL implemented for them. Most HWLs that changed during the third period moved from no HWL to either voluntary tobacco industry HWLs (“Vol HWL” in Table 2) or a mandated definite health messages (“definite HWL”). During the final period (2003–2012), most of the new HWLs (170 out of 198) were at least within the category of “definite HWL,” though 37 countries kept lower-level HWLs or had no HWL.

Effect of FCTC on Health Warning Label Adoption

Countries that began with mandated HWLs reached FCTC compliance (i.e., both GWLs and rotating HWLs) more rapidly and at higher levels than countries that started with voluntary industry HWLs (Figure 1). By 2012, 82 of 122 countries (66%) with initial mandated HWLs reached FCTC compliance compared with only 13 of the 65 countries (20%) with initial voluntary industry HWLs (P < .001 by χ2). The median year in which countries reached FCTC compliance (median = 2009; IQR = 2008–2011) was not different for countries that began with a mandated HWL than for those that started with a voluntary industry HWL (median = 2009; IQR = 2008–2012).

Countries that began with a mandated HWL may have been more likely to enact GWLs (but not HWLs that do not have graphics) than countries that started with voluntary industry HWLs (Figure 1). By 2012, 44 of 122 countries with an initially mandated HWL (35%) had GWLs, compared with only 7 (11%) of 65 with a voluntary industry HWL (P < .001). Perhaps reflecting the more recent introduction of GWLs, the median years that GWLs were enacted were similar for countries that had an initially mandated HWL (median = 2010; IQR = 2006–2012) and voluntary industry HWL (median = 2008; IQR = 2008–2011).

Countries That Began With Mandated Health Warning Labels

For each year since ratification of the FCTC, the hazard ratio for a country being FCTC-compliant increased significantly by a factor of 1.27 per year (95% confidence interval [CI] = 1.11, 1.45) and for a GWL by a factor of 1.40 per year (95% CI = 1.13, 1.74; Table 3). For each year since the adoption of the first mandated HWL, the hazard ratio for FCTC compliance increased significantly by a factor of 1.06 per year (95% CI = 1.03, 1.08) and for having a GWL by a factor of 1.08 per year (95% CI = 1.03, 1.13). The stronger the score for a country’s initial HWL, the earlier the country reached FCTC compliance with initially mandatory HWLs (P = .01).

Table

TABLE 3— Cox Proportional Hazards Model for Framework Convention on Tobacco Control Compliance and Graphic Warning Labels on Cigarette Packages

TABLE 3— Cox Proportional Hazards Model for Framework Convention on Tobacco Control Compliance and Graphic Warning Labels on Cigarette Packages

FCTC Compliance
GWL
PredictorsHazard Ratio (95% CI)PHazard Ratio (95% CI)P
Countries initially with mandated HWL (n = 122)
 Time since FCTC1.27 (1.11, 1.45)≤ .0011.40 (1.13, 1.74).002
 Time since first HWL1.06 (1.03, 1.08)≤ .0011.08 (1.03, 1.13).001
 Initial HWL score1.25 (1.05, 1.49).0141.35 (0.93, 1.97).117
WHO region (Ref = Europe)
 Americas0.31 (0.16, 0.61)≤ .0012.31 (0.94, 5.65).068
 Southeast Asia0.18 (0.06, 0.51)≤ .0010.92 (0.20, 4.18).917
 Africa0.14 (0.05, 0.38)≤ .0010.33 (0.04, 2.63).298
 East Mediterranean0.17 (0.08, 0.36)≤ .0011.76 (0.74, 4.18).203
 West Pacific0.60 (0.31, 1.17).1331.98 (0.66, 5.88).221
Countries with industry self-regulatory HWLs (n = 65)
 Time since FCTC1.68 (0.95, 2.97).073
 Time since first HWL1.11 (1.05, 1.17)≤ .001
 Initial HWL score2.18 (1.56, 3.06)≤ .001

Note. CI = confidence interval; FCTC = Framework Convention on Tobacco Control; GWL = graphic warning label; HWL = health warning label. Time since FCTC is the number of years since a country ratified the FCTC. Time since first HWL is the number of years since a country passed a first mandated HWL. Initial HWL score is for the first mandated HWL a country passed.

There was significant geographical variability in the results. When we controlled for the other variables, all WHO regions had significantly different (lower) chances of having reached FCTC compliance than the European region (P ≤ .001) except the West Pacific region (P = .133). There was a suggestion that the Americas were more likely to have passed a GWL (P = .068) than were other regions.

Figure A and Table A (available as supplements to the online version of this article at http://www.ajph.org) show the results for rotating warning labels, which are qualitatively similar to the results for FCTC-compliant warning labels.

There was no significant effect of time since FCTC ratification on FCTC compliance for countries that started with voluntary industry HWLs. Enacting a stronger first mandatory HWL was associated with greater FCTC compliance (hazard ratio = 2.18; P ≤ .001) and with passing an initially mandatory HWL later (hazard ratio = 1.11 per year; 95% confidence interval = 1.05–1.17). There was also some suggestion that time since FCTC compliance had an effect. The hazard ratio for FCTC compliance increased by a factor of 1.68 each year since ratification of the FCTC (P = .07).

As seen in other tobacco control activities,12,13 the tobacco industry delayed the passage of HWLs as few countries that started with industry-volunteered policies reached FCTC compliance. Countries that started with industry voluntary HWLs were slower to progress to FCTC-compliant HWLs, and this progress was not related to signing the FCTC, which differed from countries that started with mandated HWLs. The number of countries with voluntary HWLs varied by region and most countries with voluntary HWLs were in Africa (Table 4). In Africa, this pattern may reflect a lack of state capacity and resources, and tobacco industry interference.22 Voluntary HWLs pulled the median number of transitions down during later periods as very few countries that began with voluntary HWLs advanced to higher levels.

Table

TABLE 4— Number of Countries With Voluntary Health Warning Labels on Cigarette Packages by WHO Region

TABLE 4— Number of Countries With Voluntary Health Warning Labels on Cigarette Packages by WHO Region

WHO Region Countries, No.
Europe5
Americas16
Southeast Asia2
Africa33
East Mediterranean6
West Pacific7

Note. WHO = World Health Organization.

The FCTC had a positive effect on passage of stronger HWLs and GWLs and the passage of HWLs generally. The rate of HWL enactment increased over time with the initial legally required HWLs becoming stronger, though the incremental improvement between different HWLs (measured as the number of steps between HWLs scores) remained stable. Among countries that began with mandated HWLs, FCTC signatories were more likely to pass FCTC-compliant rotating HWLs (score 5) and GWLs (score 6). Among these countries, the stronger the first mandated HWL, the more likely the countries were to reach FCTC compliance.

The significant effect of time since signing the FCTC on the hazard model statistic of countries that initially had mandatory HWLs likely reflects the social and political process that led to ratification of the FCTC. Countries, nongovernmental organizations, and other entities came together to develop the FCTC from years of debate and consensus building.23,24 The process that led up to the ratification of the FCTC likely affected the passage of HWLs, which was, in turn, augmented by signing and ratifying the FCTC.

We analyzed data from more than 40 years of tobacco industry and other documents related to cigarette pack HWLs after an extensive search of multiple sources of information. However, it is always possible that some data are missing from the analysis. Furthermore, we dropped the Philippines, Hungary, Japan, Uganda, Azerbaijan, the Bahamas, and Iceland from the primary event history analysis because the data from these countries included a transition from a stronger HWL to a weaker HWL, a voluntary HWL, or no HWL. A sensitivity analysis using the most recent versions of the HWL for these countries did not substantially change the conclusions of the event history analysis. We did not include 16 non–United Nations countries and other entities (e.g., Hong Kong, Taiwan) in either analysis; results from an event history analysis (not presented) including these entities were virtually identical to the event history analysis.

Future research might investigate why HWL transitions were limited to 2 categories within each period, specifically focusing on political and social processes that limit the scope of transitions. In this regard, comparisons to implementation of other health-related policies (e.g., smoke-free laws) could yield important information on how tobacco control activities might diffuse and how that process can be improved. Indeed, the food industry has recently implemented voluntary nutritional labels in an effort to prevent several governments and international health organizations from developing and mandating standard nutrition labeling.25,26 In addition, future analyses might consider building on our current findings by incorporating sociological factors including baseline and change in country-level GDP, type of and change in governmental structure, and other related policies that may be in existence in each country.

These results illuminate an important relationship between international treaties and processes that affect noncommunicable disease burden. The delaying effect of voluntary HWLs on the implementation of mandated HWLs may serve as a warning for other noncommunicable diseases. In particular, there are major financial interests that would benefit from halting health-related interventions for other areas, such as food industry activities that affect the obesity epidemic. Policymakers should avoid accepting voluntary agreements with tobacco companies as an alternative to mandated tobacco control policies.

Acknowledgments

This work was supported by National Cancer Institute grants CA-113710 and CA-087472 and by a grant from the Erkki Poikosen Säätiö.

Notes. The funding agencies played no role in the conduct of the research or preparation of the article. H. Hiilamo served without renumeration as an expert witness for a plaintiff in tobacco litigation, Salminen v. Amer Sports Oyj and BAT Finland in 2008 and in 2009.

Human Participant Protection

Human participant protection was not required because no human participants were involved in this study.

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Ashley N. Sanders-Jackson, PhD, Anna V. Song, PhD, Heikki Hiilamo, PhD, and Stanton A. Glantz, PhDAshley N. Sanders-Jackson and Stanton A. Glantz are with the Center for Tobacco Control Research and Education, University of California, San Francisco. Anna V. Song is with University of California Merced, Psychological Sciences, Merced. Heikki Hiilamo is with Social Insurance Institution of Finland, Helsinki. “Effect of the Framework Convention on Tobacco Control and Voluntary Industry Health Warning Labels on Passage of Mandated Cigarette Warning Labels From 1965 to 2012: Transition Probability and Event History Analyses”, American Journal of Public Health 103, no. 11 (November 1, 2013): pp. 2041-2047.

https://doi.org/10.2105/AJPH.2013.301324

PMID: 24028248