摘要：The legislation of health warning labels on cigarette packaging is a major focus for tobacco control internationally and is a key component of the World Health Organization’s Framework Convention on Tobacco Control. This population-level intervention is broadly supported as a vital measure for warning people about the health consequences of smoking. However, some components of this approach warrant close critical inspection. Through a qualitative content analysis of the imagery used on health warning labels from 4 countries, we consider how this imagery depicts people that smoke. By critically analyzing this aspect of the visual culture of tobacco control, we argue that this imagery has the potential for unintended consequences, and obscures the social and embodied contexts in which smoking is experienced. Visual imagery of the health effects of smoking has a long history in the context of antitobacco campaigns. Such images featured prominently in Victorian era antismoking literature, 1,2 and visual representations of the deleterious effects of smoking on the body have been a continuous thread in modern-day tobacco control and public health iconography. The first warning labels mandated on cigarette packaging were text-based only, enacted in the United States a year after the 1964 Surgeon General’s Report decisively linked smoking to cancer and other adverse health outcomes. 3 In 1965, the US Federal Cigarette Labeling Act required cigarette cartons and packs to carry the warning, “Caution: cigarette smoking may be hazardous to your health.” 4 (p13) The addition of pictures to warning labels on tobacco packaging is a relatively recent phenomenon, legislated first in Canada in 2000. 5 Following Canada’s lead, many other countries have since followed suit, with text and picture-based warnings required in 63 countries worldwide as of 2012. 6 The use of visual imagery (referred to specifically as “health warning labels”) on tobacco packaging has been driven by the World Health Organization’s Framework Convention on Tobacco Control and is based on the premise that “a picture says a thousand words.” 6 (p1) Article 11 sets out clear standards for health warning labels, which are expected to cover “as much of the principal display areas as possible.” 7 (p34) For tobacco control advocates, the impetus for visually based warning labels was clearly protection and empowerment against the tobacco industry’s tactics—for children and youths, who were seen as particularly susceptible to “prosmoking” media imagery, and for consumers, who had been subject to industry “fraud” and misinformation about the health risks and consequences of smoking. 5 (p356) However, although the ostensible purpose of the visual imagery used on health warning labels is to educate smokers about the effects of smoking, it draws some of its impetus from the assumption that the subjective emotional response the images may provoke will force smokers into “realizing the harm done to their bodies.” 8 (p358) In other words, the transition from text-based to visual warning labels reflects a growing awareness that the labels could be used not just to transmit information but to affect behavioral change. Indeed, health warning labels on cigarette packages are seen to be even more effective than traditional print and television campaigns because they “potentially reach smokers every time they purchase or consume tobacco products.” 7 (p23) The underlying assumption is that, in contrast to similar messages presented in other mediums, the warnings are unavoidable. From a public health standpoint, a third goal of such labels is to facilitate tobacco denormalization by challenging the social and cultural acceptability of smoking, especially the glamorization of tobacco in media and popular visual culture. 9 In this respect, the visual culture of tobacco control has been heavily influenced by the tobacco industry, and aims to use its strategies and practices against it. 10 Numerous studies support the view that hard-hitting graphic labels are more effective than text-based warning labels in stimulating awareness of tobacco-related health risks and increasing motivation and intentions to quit smoking. 8,11,12 Plain cigarette packaging is seen to be particularly effective in reducing the appeal of smoking and focusing attention on the image and text of the health warning labels. 13 Australia’s introduction of plain cigarette packaging requirements in December 2012 has generated considerable interest in such legislation. However, one limitation of the available research is that responses to cigarette packages are studied in a context in which the ordinary coordinates of smoking are absent, making effectiveness very difficult to judge. 14 Critical approaches to health promotion challenge the assumption of a simplistic or unidirectional relationship between public health campaigns and their intended targets, in which audiences are passive recipients of health information. Contrary to a didactic model of health education and its emphasis on individual behavioral change, critical approaches recognize the structural context of smoking and the social, historical, and political circumstances in which antismoking messages are deployed. Thus, multiple readings and responses on the part of message recipients are inevitable. In the arena of smoking cessation, this includes the potential for negative responses, ranging from context dissonance 15 to defiance or resistance. 16–18 This recognition challenges mainstream and top-down approaches in health promotion, which may assume that health-related behavior change is merely a matter of better education for at-risk individuals and groups (i.e., that programmers and policymakers just need to get the message right). These approaches also highlight the need for public health policies to move beyond an exclusive emphasis on questions of efficacy to consider the ethics of the strategies employed (i.e., even if they do work, at what cost?). Without careful consideration of the ethical implications and unintended consequences of such messaging, the “war against smoking” may instead become a counterproductive “war against smokers.” Our analysis of health warning labels on cigarette packaging has been informed by previous research on the visual culture of public health, which suggests that health promotion and education campaigns are constitutive of deeply embedded cultural understandings of health, illness, and social relations of power. 19–21 From this standpoint, it is useful to consider how health-related imagery presented as scientific and objective privileges particular ways of seeing and defining both the bodies and identities of those who are “healthy” and pathological bodies at risk for illness. 22–24 As critical public health scholars suggest, health promotion campaigns not only reinforce a normative imagery of health but can also contribute to social exclusion, stigmatization, and dehumanization when graphic and confronting images designed to provoke disgust are used. 16,25 These tendencies have been explored in the context of issues such as injury prevention and disability, 26,27 HIV/AIDS, 22,28,29 obesity, 25 and substance use, including alcohol 30 and smoking. 31,32 For example, analyses of antitobacco messages for pregnant women 33 and campaigns directed toward adolescent girls 34 suggest that the former promote the notion of the “bad mother” and neglect smoking by fathers and other men, whereas the latter reinforce the idea that what is most valuable about women is their external, physical appearance. 35 We analyzed the visual culture of tobacco control as represented by cigarette health warning labels in the context of 4 countries, and interpreted what this reveals about smoking as a social identity and practice. Such labels provide openings through which to see the “densely elaborated iconography” 36 (p107) of tobacco control and how it conceptualizes smoking and people labeled as smokers. We contend that the currently used and proposed sets of health warning labels ground understandings of smoking and its effects in ways that obscure certain dimensions of the practice while foregrounding and prefiguring others. In particular, they frame smoking as an individual risk behavior, one entirely isolable from its social context. Our approach is critical of such framing, and cuts against both its emphasis on a biomedical imagery of the “diseased and dying” body and its diminishment of agency. 9
