The report shows that 118 countries and territories—covering 58 percent of the world’s population—now require graphic cigarette warnings (also called pictorial warnings) with 107 of them requiring warnings that cover at least 50 percent (on average) of the front and back of the pack. In contrast, cigarette packs in the U.S. only contain text warnings on the sides of cigarette packs that haven’t been updated since 1984. Research has shown that these text-only warnings are stale, unnoticed and a major impediment to greater progress in reducing cigarette smoking in this country.

The U.S. has fallen woefully behind the rest of the world in requiring strong and effective cigarette warnings that reduce smoking and save lives. This report underscores the urgency with which the U.S. Food and Drug Administration should act to issue, finalize and implement a rule requiring graphic health warnings on cigarette packs and advertising. In September, a federal court ordered the FDA to expeditiously issue such a rule as mandated by a 2009 federal law that requires graphic warnings covering the top half of the front and back of cigarette packs and covering 20 percent of cigarette ads.

The federal court ruling by U.S. District Judge Indira Talwani of the U.S. District Court for the District of Massachusetts was in response to a lawsuit filed in October 2016 by the Campaign for Tobacco-Free Kids and seven other public health and medical groups, as well as several individual pediatricians. Judge Talwani agreed with the health groups that the FDA has both “unlawfully withheld” and “unreasonably delayed” agency action to require the graphic warnings.

Studies around the world have shown that graphic warnings are most effective at informing consumers about the health risks of smoking, preventing children and other nonsmokers from starting to smoke, and motivating smokers to quit. Requiring graphic cigarette warnings in the U.S. will protect kids, save lives and reduce tobacco-related health care costs, which total $170 billion a year.

The FDA’s initial attempt to require graphic warnings was blocked in 2012 by a three-judge panel of the U.S. Court of Appeals for the D.C. Circuit, which ruled 2-1 that the specific warnings proposed by the FDA violated the First Amendment. However, ruling in a separate case in 2012, the U.S. Court of Appeals for the Sixth Circuit upheld the law’s underlying requirement for graphic warnings, finding this provision did not violate the First Amendment. The U.S. Supreme Court declined to hear a tobacco industry appeal of this ruling.

Together, these two court decisions mean the FDA is still legally obligated to require graphic health warnings, using different images from those struck down by the D.C. Circuit. The U.S. District Court decision delivered in September means the FDA will be under a court-ordered expedited schedule for issuance of a final graphic warnings rule.

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