Industry manipulation of pictorial health warning labels in Pakistan.

Approximately 10.5% of adults in Pakistan (about 13 million) smoke cigarettes,1 causing 134 000 deaths annually.2 To reduce the burden of disease, the Pakistan government implemented a requirement in 2010 for 40% pictorial health warning labels (HWLs) that depicted mouth cancer. A 2017 ruling to increase HWL size was implemented in August 2018 (50% throat cancer image) and August 2019 (60% gangrenous foot image).3 4 Pictorial HWLs increase smokers’ quit attempts, deter initiation of use among non-smokers, and prevent relapse in former smokers.5 In 2013, only 58% of unique packs with the current, in-rotation HWL were compliant with size, location, text contrast and text size requirements in Pakistan.6 In 2019, compliance with size, location and text language requirements was 82% (largely due to size compliance improvements) for unique packs displaying the most recent gangrenous foot HWL7; however, poor HWL …