When I prescribe a new medication for a patient, I attempt to give them an overview of the medication, including its mechanism, benefits, and potential adverse effects. Not infrequently, the same patient who agrees in the office to take the new medicine will return a few days later refusing to take it, petrified of the side effects they read about on the Internet. I have always wondered why those same patients who refuse to take a relatively benign medication will completely ignore the adverse effects of the cigarette they put in their mouth 20 times a day. That may be about to change.

Last week the FDA announced changes to the health warnings on cigarette packaging and advertisements effective September 2012. The new warnings will replace the Surgeon General's Warning that currently appears on cigarette packs, cartons, and print ads (smokeless tobacco seems to have escaped this new regulation). According to the FDA's website, the new graphic photos are intended to increase awareness of specific health risks associated with smoking, encourage smokers to quit, and empower youth to say no to tobacco. They are expected to have a significant public health impact by decreasing the incidence of smoking and its associated morbidity, mortality, and health care costs. The nine photos that will be used were selected out of a group of 36 proposed images following research on their effectiveness at communicating the message and a public comment period. The images will comprise 50% of the front and rear panels of each package and will be accompanied by simple statements describing the dangers of smoking.

Initially, I was skeptical about these new photos and their accompanying messages but I have been so impressed by the Idaho and Montana Meth Projects' graphic advertising campaigns that I think it just may work. Instead of pretty colors and exotic animals, smokers will be faced with photos of babies exposed to cigarette smoke, cancerous oral lesions, and sick versus healthy lungs, among other pictures. Each warning will be accompanied by the 1-800-QUIT-NOW phone number so smokers have access to cessation resources even as they reach for a cigarette.

I hope these new packaging images will be especially beneficial in reducing teenage smoking rates and discouraging first-time, youth smokers. Kids are often very responsive to gross photos. A simple, scary picture can help make the connection between an action and its consequence better than any story I could ever tell them. Another image-based program that appears to be very effective at discouraging kids from smoking is the American Academy of Family Physician's Tar Wars program. The objectives of this program, geared towards fourth and fifth graders, are to motivate children to be tobacco free, empower them to make good health decisions, and promote personal responsibility. Students are presented with the short-term effects of smoking and are taught to critically examine tobacco advertisements. The program is totally interactive and, in my experience, clearly conveys the benefits of a tobacco-free lifestyle. One of the program activities, which clearly demonstrates the effects of smoking on lung function, involves breathing through a straw at rest and while running in place to simulate the sensation of lung obstruction. The kids were amazed at how difficult it is to run and play when you can hardly breathe.

Realistically, our patients know smoking is bad for them. Most of them are simply powerless to quit the addiction to nicotine unless they are extremely motivated, supported, and encouraged to do so. Studies have shown that patients are more likely to quit smoking if their health care provider recommends it. So, we are not off the hook yet. These labeling changes present us with another opportunity to engage our patients in a discussion about tobacco use. We still need to ask them if they smoke (or use tobacco) and help them act to quit. It also helps to set a good example and not smoke ourselves. If all else fails, we can change our language to reflect the “side effects” of smoking and perhaps someone will take our advice seriously.

Amy Klingler practices primary care at the Salmon River Clinic in Stanley, Idaho.