Is health warning label compliance a country or manufacturer issue: a 9-country multi-year study

Background Two agents are responsible for producing effective cigarette health warning labels (HWLs): governments ensure HWL legislation is comprehensive with clear implementing rules, and tobacco companies are responsible for implementation. We determined what factors contribute to noncompliance with HWL legislation in nine countries that improved their HWL requirements over a three-year period. Methods Unique cigarette packs were purchased in 2013 (N=1164) and again in 2015-2017 (N=1413) across nine low- and middle-income countries (Bangladesh, Brazil, China, India, Indonesia, Philippines, Russia, Thailand, and Vietnam) that improved their HWL legislation. Country-specific HWL compliance codebooks were created to assess up to four HWL compliance indicators: location, label size (coverage), label elements (e.g., text or background color, borders), and text size. Results HWL compliance in…