It once was difficult for people to imagine that smoking might be harmful, as Siddhartha Mukherjee documents in The Emperor of All Maladies (Scribner, 2010). He quotes Oxford epidemiologist Richard Peto, who explained that during the 1940s, when almost all U.S. men smoked, "asking about an association between tobacco and cancer was like asking about an association between sitting and cancer."

Today, things are different, to the point where the U.S. Food and Drug Administration (FDA) has now released a series of graphic, often disgusting warnings that will soon adorn every pack of cigarettes sold in this country. To paraphrase the one-time catchphrase for Virginia Slims: We've come a long way.

Under the new rules, tobacco companies have until September 2012 to redesign their packaging so that each pack features one of the nine hard-to-miss warnings, which are much more direct than what Americans are used to and will take up more space on each box—50 percent of the front and the back. The new warnings skip the mention of any surgeons general and get right to the point, with text such as, "WARNING: Smoking can kill you," and "WARNING: Cigarettes cause cancer."

The accompanying images—which include a cancerous lip, a man smoking through a hole in his neck, and a stitched-up corpse—are difficult to ignore. (According the Washington Post, the FDA considered but ultimately rejected even more morbid imagery of corpses in coffins and morgues.)

Each label also includes the number 1-800-QUIT-NOW, a government-sponsored smoking cessation hotline.

"These labels are frank, honest and powerful depictions of the health risks of smoking and they will help encourage smokers to quit, and prevent children from smoking," Health and Human Services Secretary Kathleen Sebelius said in a prepared statement. "President Obama wants to make tobacco-related death and disease part of the nation's past."

The new warnings, first proposed in November 2010, are the result of the widely supported Family Smoking Prevention and Control Act, which also gave the FDA the power to regulate tobacco products and banned flavored cigarettes and clove cigarettes.

Canada paved the way for warning labels with pictures back in 2000, and since then, they have been implemented in more than 30 countries. (Brazil's warnings are especially gruesome.) Several studies and government surveys have found that warning labels that use pictures are more difficult to ignore and more effective in educating consumers about the risks of smoking and in motivating smokers to quit. Still, as one 2007 paper noted, "warning labels are one component of comprehensive tobacco control and smoking cessation efforts."

For advocacy groups such as the American Cancer Society, these types of warnings have been a long time coming.

In the summer of 1957, Surgeon General Leroy E. Burney wrote a cautious, ultimately historic statement that marked the U.S. Public Health Service's first warning of the link between smoking and cancer: "It is clear that there is an increasing and consistent body of evidence that excessive cigarette smoking is one of the causative factors in lung cancer."

But the real bombshell came in 1964, when a commission organized by the Kennedy administration—after prodding from the American Cancer Society, the American Heart Association and other groups—completed its review of more than 7,000 studies. The commission's official report laid out the grim findings. Smokers had a 70 percent higher mortality rate than non-smokers and were almost 10 times as likely to develop lung cancer. Smoking was also correlated with emphysema, heart disease, chronic bronchitis and low birth weight in newborns. That's all old news now, but at the time, the report rocked a happily chain-smoking nation, not to mention the tobacco industry.

The very next year, after not-so-successfully battling the tobacco lobby, Congress passed a law requiring a timid warning on the side panels of cigarettes packs (but not in ads): "Caution: Cigarette Smoking May Be Hazardous to Your Health." The message was made slightly more emphatic in 1969, when the Public Health Cigarette Smoking Act also banned cigarette advertising on television and radio. But it was not until the Comprehensive Smoking Education Act of 1984 that Congress mandated the Surgeon General's Warnings that are so ubiquitous today and will themselves seem so toothless in just a few years.


Image: Courtesy of FDA