Compliance in Jeopardy: Investigating the Manipulation of Pictorial Health Warning Labels Printed on Cigarette Packs and the Impact of Pack Shape in Mexico.

Background: Large health warning labels (HWLs) with pictures on tobacco packaging are an effective policy to communicate the harms of tobacco use and discourage consumption. The tobacco industry also uses packaging as a key communication tool, altering its design to appeal and attract specific groups. Few studies have assessed compliance of HWLs noting ways that the tobacco industry exploits packaging and labeling regulation loopholes. This study assessed compliance with HWL requirements on cigarette packs from Mexico. Methods: The analysis included cigarette packs purchased in October and November 2021 using the Tobacco Pack Surveillance System (TPackSS) protocol in 12 low, middle, and high socioeconomic areas in each of five cities: Mexico City, Guadalajara, León, Durango, and Mérida. In total, 191 unique cigarette packs, with Mexican HWLs that were current at the time of data collection, were assessed for compliance based on HWL location, size, label elements (ie, text and background colors), and use of exact images as published by the government. Compliance with HWL size was examined by pack shape and type. Results: All the cigarette packs that were assessed were compliant with HWL location and the majority (98%) complied with label elements; 85% complied with HWL size. Beveled edge packs were less likely to be compliant in terms of warning size than packs without them (P < 0.05). Only 27% of packs had the image appearing exactly as specified by the Mexican government, obscuring the intended visual composition and diverting attention away from the focal point-thus, diminishing the image's impact. Conclusions: Countries, including Mexico, implementing new or revising current HWL policies should establish enforcement procedures to ensure correct implementation of HWLs and prevent loopholes that can be exploited by the tobacco industry. Part of this would be to consider standardized tobacco pack shape to allow for better HWL implementation and effectiveness.