Abdul Wahab Shahid
Tobacco use has been a serious public health problem in Pakistan for decades. According to Ministry of National Health Services about 160,000 deaths per year are caused by it. (Ministry of National Health Services, Regulations and Coordination, 2019). Pictorial health warnings on cigarette packs are a low-cost response and are widely used to raise awareness, especially among young people. How efficient these are depending on their size and on how often they are renewed, and on both counts, Pakistan has fallen behind.
Pakistan introduced pictorial warnings in 2010, covering 40% of the front and back of cigarette packs. In 2015 the health ministry announced an increase to 85%. The plan was postponed several times and never took effect. A 2017 statutory regulatory order (SRO) replaced it with staged increases to 50% in 2018 and 60% in 2019 (Tobacco Control Laws, n.d.). Health officials later told Reuters that the ministry had changed the 85% requirement under industry lobbying, and records showed that Philip Morris and BAT representatives attended at least two meetings of the inter-ministerial committee that reviewed the rules (Reuters, 2018).
Article 11 of the WHO FCTC calls for clear, large and visible warnings, and Pakistan, a Party to the treaty since 2004, is bound by it. The article says warnings should cover 50% or more of the principal display areas and never less than 30%, and the guidelines encourage Parties to go further (World Health Organization, 2003). Many have. In South Asia, Nepal requires 90% of the pack, India 85% and Sri Lanka 80% (Dawn, 2019). Globally, Timor-Leste and Türkiye lead with 85% on the front and 100% on the back, and New Zealand requires 75% and 100% (Canadian Cancer Society, 2025). At 60%, Pakistan is behind India, Nepal and Sri Lanka.
The 2019 round was a real step forward. A notification issued in January 2019 introduced an image of gangrene and set the size at 60% of the front and back of cigarette packs (Ministry of National Health Services, Regulations and Coordination, 2019). Pack surveys later found that manufacturers, multinational and domestic alike, had tinted, lightened or cropped the images, which made the warnings less visible (Crespi et al., n.d.). Since then little has changed. The Pakistan National Heart Association (PANAH) says there has been no progress on pictorial warnings for six to seven years (The News, 2026).
Warnings that are small, tinted or cropped lose their force, and it becomes easier for people to overlook the harm tobacco does, to smokers and non-smokers alike. Smokers also get used to the same image over time, which is why the guidelines treat regular renewal as part of warning policy. Pictures work across language and literacy barriers, so they matter most for young people. Large graphic images make smoking look like a health hazard instead of an accessory, and over time they add to the stigma around tobacco use.
The health ministry has tried to act. By PANAH’s account, it prepared a summary proposing larger warnings, which the Ministry of Law vetted and the Cabinet Committee on Legislative Cases (CCLC) approved before it went to the federal cabinet. A press release afterwards said that all summaries before the cabinet had been approved, but the official minutes later showed that this one had been rejected. PANAH has written to the Cabinet Secretary twice and has received no explanation (The News, 2026). The episode shows that the ministry can build a case, win legal and committee clearance, and still lose at the last stage without a public reason. That is a governance problem as much as a health one.
Revenue interests help explain the delay. The health minister told Reuters in 2018 that the finance ministry and the federal revenue board had a soft spot for an industry that is one of the country’s biggest taxpayers (Reuters, 2018). As long as tobacco is treated mainly as a source of revenue, delay is the likely outcome.
Four changes would help. First, the warning size should rise from 60% to at least 85%, as the ministry itself planned in 2015 and as India and Nepal already require. Second, attractive packaging should be restricted and plain packaging adopted, so that the pack does less to sell the product. Third, the images should be renewed on a regular schedule and show different health effects each time, so that the warnings stay hard to ignore. Fourth, the process should be open: the cabinet should give written reasons when it rejects a health ministry proposal, and government interactions with the industry on this issue should be recorded and published, as the Article 5.3 guidelines recommend. Civil society groups such as PANAH have kept up the pressure, and they need consistent backing from the government.
The ministry has already shown that it can take a case for larger warnings through the legal and committee process. What is missing is a cabinet decision, and a decision-making process that explains itself. Until the pending proposal is approved, Pakistan’s warnings will stay at 60% while its neighbors move ahead.
