Nepal leads with 100% graphic health warnings in tobacco: a global benchmark in tobacco control

Nepal has achieved a historic public health milestone by becoming the first country in the world to implement 100 % pictorial health warnings on cigarette packs. Legislation has been passed and the Government of Nepal is notifying all tobacco industries about the new health warning requirements, including a mandatory warning picture. Industries are given a preparation period, and full implementation will take effect from August 2025. This bold step aims to combat tobacco use, which causes one in ten deaths worldwide and contributes to multiple non-communicable diseases, including cancer, chronic respiratory diseases and cardiovascular diseases (CVDs). In 2021, tobacco was responsible for an estimated 28,100 deaths in Nepal, accounting for 23.7% of total deaths, making it the third highest risk factor for death and disability. Tobacco use kills more than 75 Nepalis every day. Smoking also harms Nepal’s economy, costing 32,818,579,754 Nepalese rupees (more than US$235,000,000) every year. Nepal’s policy sets a new global standard and provides an important model for other nations, particularly low- and middle-income countries (LMICs).

For years, cigarette packaging has been a marketing tool for the tobacco industry to reinforce brand visibility and increase the social acceptability of smoking and people who smoke. To counter this, the WHO’s Framework Convention on Tobacco Control (FCTC) recommends replacing tobacco packaging with large graphic warning labels (GWLs) to inform users of health risks and reduce their attractiveness. However, the tobacco industry has repeatedly challenged regulations mandating pictorial warnings, citing violations of freedom of expression, the expropriation of intellectual property, and infringement of trade agreements. Courts have consistently dismissed these claims.

Studies in Nepal and other countries have shown that larger GWLs significantly increase awareness of smoking-related health risks, motivate cessation attempts and reduce consumption. Research from Nepal has consistently shown that pictorial health warnings can significantly increase quit intentions of people who smoke, encourage quitting attempts, and reduce the appeal of smoking among young people. For instance, a 2021 study conducted in a region of Nepal with high levels of illiteracy found that pictorial warnings, covering 90% of packs at the time, encouraged more than half of the respondents to attempt to quit smoking. These findings highlight the potential of graphic health warnings to promote behavior change, particularly in LMICs, where tobacco use remains high. Nepal’s recent policy represents one of the strongest implementations of these guidelines, demonstrating resilience against industry interference. So far, there have been no reports of any pushback or response from the tobacco industry.

Nepal ratified the FCTC in 2006 and has made significant progress in tobacco control, introducing packaging regulations in 2011 that mandated 75% health warnings, which were later expanded to 90% in 2015. Building on this progress, Nepal is set to implement the world’s largest pictorial health warnings by August 2025, covering 100% of both front and back packaging surfaces, with clear, colorful images and Nepali text. This bold step reinforces the country’s political will and leadership in tobacco control and offers valuable lessons for other nations seeking to reduce tobacco use and its associated harm. The policy was introduced by the Ministry of Health and Population (MoHP) with support from public health organisations, anti-tobacco advocacy groups and international bodies like the WHO and The Union. Civil society organisations and health experts also played a crucial role in pushing for stronger regulations. The Health Promotion & NCD and Tobacco Control Section under the National Health Education and Communication Center leads tobacco control efforts in Nepal. It supports the MoHP in policy-making, regulates tobacco marketing and ensures compliance with guidelines. The section also coordinates with international bodies, develops annual action plans and conducts health promotion programs, including school-based initiatives, to drive behavior change.

Graphic health warning labels on tobacco packages are a cost-effective method of raising public awareness about the dangers at the time of sale and use. In Nepal, cigarette packs are easily accessible. The most commonly sold cigarette brand costs approximately $2.74 per pack (20 cigarettes). Despite a tobacco tax rate of 31.4%, cigarettes have not become less affordable. The enforcement of age restrictions on tobacco sales to individuals under 18 remains weak, highlighting the need for stricter government monitoring. Additionally, while regulations prohibit the sale of tobacco products within 100 meters of educational institutions, healthcare facilities, child welfare homes, elder care centres and other designated public spaces, implementation remains inconsistent. This policy is intended to encourage people who smoke to quit smoking. Strengthening enforcement mechanisms is essential to ensure compliance with these regulations.

While the implementation and impact of this policy are yet to be seen, this critical step towards better informing consumers of the harms of tobacco use marks a significant public health achievement. Nepal’s leadership in tobacco control offers valuable lessons for global efforts to reduce tobacco consumption and its associated health burdens.

Kiran Paudel

Nepal Health Frontiers, Tokha-5, Kathmandu Nepal

kiranpaudel59@gmail.com

Kamal Gautam

Rethink Lab, Kathmandu, Nepal

Sangam Shah

Tribhuwan University, Institute of Medicine, Kathmandu, Nepal

Roman Shrestha

Nepal Health Frontiers, Tokha-5, Kathmandu Nepal

What does future hold for tobacco and nicotine control in a second Trump term?

The first Trump administration raised the legal age for purchasing vape products and tobacco products from 18 to 21 in 2019. The tobacco industry clearly learned their lesson and it was recently reported that RAI Services Co., a subsidiary of Reynolds American was the top corporate donor to the most recent Trump campaign donating $10 million in 2024. This is a significant leap from their 2016 donation of $25,000 funded by employee contributions and a $1 million contribution to Trump’s 2017 inauguration. The Washington Post reported in September 2024 that this recent move was driven by a pro-Trump lobbyist whose firm represents Reynolds. Following President Trumps reelection, tobacco company Altria made a $1 million contribution to the Trump Inauguration committee.

Many tobacco control advocates expressed disappointment that the Biden administration did not finalise the ban on menthol cigarettes and flavoured cigars before leaving office. A ban on menthol flavouring in cigarettes was predicted to result in significant decreases in morbidity and mortality as well as associated healthcare costs among people who smoke, with particular benefits for certain population groups who have been aggressively targeted by industry advertising and marketing and consequently are more likely to smoke menthol cigarettes. In response to the proposed ban, the tobacco industry had waged an extensive campaign against it. While it was hoped that President Trump’s personal dislike of smoking would make him an ally to advance tobacco control policy, disappointingly, soon after taking office in January 2025, the Trump administration withdrew the proposed menthol ban. Shares of British American Tobacco, Altria and Philip Morris saw an increase in value following the announcement.

This was not the first time that the president’s pro-business stance won out over public health. In 2019, the president signalled a complete ban on flavoured e-cigarettes, but subsequently changed his mind following indications that such a ban would not be popular among his supporters and might jeopardise his re-election bid. In the run-up to the 2024 election, he vowed to ‘ save vaping’ in a social media post. The Food and Drug Administration is the agency with authority to regulate the manufacture, marketing, sale, and distribution of tobacco products. It finds itself in the crosshairs of Robert Kennedy, newly appointed secretary for Health and Human Services, as well as the newly formed Department of Government Efficiency, with reports of layoffs in February 2025 that could impact the agencies' ability to review the safety of new tobacco and nicotine products among its many other functions.

World No Tobacco Day 2025

May 31st marks the 28th World No Tobacco Day. This year’s theme is ‘Unmasking the Appeal: Exposing Industry Tactics on Tobacco and Nicotine Products,’ aimed at highlighting tobacco industry tactics to make their products more appealing, particularly to young people. The theme is more relevant than ever as more and more research reveals how the tobacco industry is updating their tried and tested playbook of tactics to today’s landscape, using social media and influencers to market old and new products with sleek designs and appealing additives to children and young people.

Vaping is generally portrayed positively on Instagram and YouTube, and content typically does not flag any age restrictions or health warnings. Influencers on Instagram and TikTok can be seen as credible sources of information. Nicotine pouches and e-cigarettes are promoted as lifestyle products by companies on social media platforms with claims that the products are non-addictive with comparisons to weight loss drugs like Ozempic. These tactics are all reminiscent of tobacco industry advertising and marketing of combustible tobacco products. A systematic review and meta-analysis from 2023 found links between exposure to e-cigarette or tobacco products on social media and use or pro-use attitudes among youth. More recently, research published in 2024 from the UK found that social media use is associated with increased risk of cigarette smoking and e-cigarette use, and researchers from Germany, showed links between e-cigarette use among adolescents and e-cigarette use in influencer videos.

If you have organised an event for World No Tobacco Day 2025, please get in touch with ruth.canty@flinders.edu.au and let us know how it went.

Tobacco industry interference in Spanish tobacco product waste management

On 22 October 2024, the Spanish government released Royal Decree 1093/2024 to regulate the management and cleanup of waste from tobacco products. The decree applies to tobacco product filters and single-use filters that contain plastic used with tobacco products, to comply with the European Directive (EU ) 2019/904 of the European Parliament and the Council of 5 June 2019.

Following the ‘polluter pays’ principle, the Royal Decree mandates that the tobacco industry bears the cost of cleanup, which at first appears to be a victory for tobacco control and the environment. However, there are complicating factors, as it provides opportunities for the tobacco industry to greenwash its image and promote itself via corporate social responsibility platforms. Unfortunately, the Royal Decree does not just force the tobacco industry to cover the costs of cleanup, but it also entrusts the tobacco industry with the management of the process of cleaning up cigarette butts and single-use plastics associated with tobacco products.

By putting the management of the cleanup on the tobacco producer as currently formulated, the Spanish Royal Decree will allow the tobacco industry to have access to and engage with representatives of municipalities and autonomous communities throughout Spain. This will also provide a platform for the tobacco industry to greenwash its image through corporate social responsibility programmes and ‘awareness raising’ campaigns, where tobacco companies claim to work to protect the environment but instead propose counterproductive measures. An example of these counterproductive campaigns is distributing pocket ashtrays and other measures aimed at normalising tobacco consumption and shifting the responsibility of cigarette pollution away from the tobacco industry and onto the person who uses tobacco.

On the same day the Royal Decree was published, the tobacco industry announced the creation of ‘Avora.’ According to its website, Avora is ‘a nonprofit association created to unite all producers of tobacco products with filters and tobacco filters. Its purpose is to support the proper management of tobacco filters containing plastic and to raise public awareness of the importance of properly disposing of cigarette butts, in line with our principles of sustainable management.’ However, as nofumadores.org and ASH point out, this mechanism is problematic as it can easily be misused by tobacco manufacturers as a lever for positive communication and to greenwash the tobacco industry’s image.

For this reason, nofumadores.org and ASH responded with a global call to action. 74 health and environmental organisations from all regions of the world united to send a letter urging the Spanish government to amend the Royal Decree. The organisations called on the government to ensure that the tobacco industry remains responsible for covering the cost of cleaning up the waste it generates but stops the tobacco industry from being involved in the management of the cleanup or using the cigarette butt cleanup for public awareness campaigns.

The 74 Spanish and international health and environmental signatory organisations (also available in English on Nofumadores.org) raised concerns that the current Royal Decree constitutes a violation of Article 5.3 of the WHO Framework Convention on Tobacco Control (FCTC). Article 5.3 prohibits tobacco industry interference in public health policies, stating that to protect such policies from the commercial interests of the tobacco industry, parties ‘should interact with the tobacco industry only when and to the extent strictly necessary to enable effective regulation of the tobacco industry and tobacco products.’ Launching Avora, with a membership exclusively including tobacco producers like Philip Morris, Imperial Tobacco, British American Tobacco, Japan Tobacco International and others, on the same day the decree was made public, raises concerns that there may have been joint planning or interactions between the Ministry of Ecological Transition and the tobacco companies.

The Royal Decree, as currently written, gives the tobacco industry the opportunity to use this campaign to greenwash its image, meaning it would be used for self-promotion and violate FCTC Article 13, which calls on countries to ban all forms of tobacco advertising, promotion and sponsorship.

ASH and Nofumadores call on any organisation managing the cleanup of cigarette butts and tobacco pollution to be independent of tobacco manufacturers, with the latter’s contribution being limited to financing the system.

Laurent Huber, Executive Director of ASH USA

Raquel Fernández Megina, President of Nofumadores.Org (Non-smokers.org Spain)

Ubaldo Cuadrado, Vice-president of Nofumadores.Org (Non-Smokers.Org Spain)

The Ploom case: defying German law

In Germany, the heated tobacco product (HTP) ‘Iqos’ from Philip Morris has been available since 2017 and ‘Glo’ from British American Tobacco since 2020. In May 2024, Japan Tobacco International (JTI) became the third tobacco company to launch its HTP ‘Ploom’ in Germany. When it was launched, Ploom was available online throughout Germany as well as in shops in four cities (Cologne, Düsseldorf, Bonn and Leverkusen).

Tobacco advertising on billboards in public spaces—except at the point of sale—has been banned in Germany since 2022. Since 2023, this has also applied to HTPs (German Tobacco Product Law). Despite the existing ban on outdoor advertising, JTI supported the Ploom launch in Cologne with an eye-catching billboard campaign from mid-May to mid-June in 2024 (figures 1 and 2). In order to circumvent the advertising ban, only the heating devices were shown on the posters, but not the tobacco sticks which are to be used with the heating device. Thus, no tobacco product itself was visible on the billboards.

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Figure 1

Outdoor advertising for Ploom in Cologne main railway station. The text says: Experience enjoyment in a new way. Find out more on ploom.com. This product is not risk-free and is only for adult users of tobacco or nicotine products. Tobacco sticks contain nicotine, which is addictive. Photo credit: Katrin Schaller.

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Figure 2

Outdoor advertising for Ploom in Cologne in an underground station. Photo credit: Ute Mons.

In fact, without the tobacco sticks, the heating device is without any function. The tobacco sticks to be used in the heating device were mentioned in a text note on the billboard: ‘This product is not risk-free and is only for adult users of tobacco or nicotine products. Tobacco sticks contain nicotine, which is addictive.’ This notice does not correspond to the legally mandated health warning on tobacco which says: ‘This tobacco product is harmful to your health and is addictive.’ The billboards highlighted the product’s new taste and were placed in underground and railway stations, where many people of all ages can be targeted when using public transport.

Upon the advice of a tobacco control advocate, the city of Cologne investigated the legality of the Ploom advertising and concluded that this form of advertising is prohibited. As a result, the city asked the advertising companies responsible for the advertising space to remove the billboards. By July 2024, there were no more Ploom billboards in Cologne.

Even though the advertising ban was ultimately enforced, the advertising was very prominently visible in highly frequented locations for several weeks. As a result, the billboard advertising for Ploom was able to reach a huge audience, including young people.

This example from Germany clearly shows that the tobacco industry tries to circumvent advertising bans for HTPs by advertising only the heating device without showing the tobacco sticks. To avoid this loophole, countries should explicitly include the heating devices in advertising bans on HTPs.

Dr. Katrin Schaller

German Cancer Research Center (DKFZ), Foundation under Public Law, Unit Cancer Prevention, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany

Record salary for BAT CEO

British American Tobacco have proposed plans for their CEO to receive a record-breaking salary package. If targets are hit, Tadeu Marroco could receive up to £18.2 million with a guaranteed pay of £1.8m across salary, pensions and benefits. This salary award is reliant on improved profitability in products like e-cigarettes, as well as the company’s share price. In 2023, Mr Marroco earned £6 million. Shareholders will vote on the proposed deal at the AGM in April.