China's cigarette health warning labels: Undermined by branding

In China, health warning labels (HWLs) on cigarette packs are text-only with two messages in rotation. We examined China's HWLs as they appear on packs, focusing on elements of design and branding that may undermine their effectiveness.

We used a systematic protocol to purchase 488 unique cigarette packs in 2023 from five major Chinese cities. The study sample consisted of the 471 packs that displayed the current HWLs mandated by China. A detailed codebook was developed to assess design elements in the HWL area (color/pattern schemes, text to background contrast, branding, etc.) and pack characteristics (brand family). Two trained coders who were native Chinese speakers independently double-coded the packs. We examined the prevalence of identified design elements and compared differences across brand families.

Colors/patterns that appeared on the pack overlapped with the HWL area on almost all packs (90%). About one-quarter (27%) of packs featured branding directly below the HWLs; significant differences were observed across brand families (p<0.05). On 11% of packs, the HWL text lacked contrast against its background. Other concerning design elements included the use of multiple colors in HWL text and background, and split HWLs.

The prevalence of appealing branding and design elements that overlap the HWL on cigarette packs, potentially diminishes the effectiveness of HWLs and makes the Chinese HWLs less prominent compared to best practices. To enhance the effectiveness of HWLs and align with FCTC Article 11, China could implement stricter HWL regulations prohibiting branding within HWLs.