Kiran Paudel, Kamal Gautam, Sangam Shah, Roman Shrestha.

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. Following the legislation being passed, the Government of Nepal is notifying all tobacco companies about the new health warning requirements. After a preparation period, full implementation will take effect from August 2025. This bold step aims puts Nepal at the forefront of combatting tobacco use, which causes one in ten deaths worldwide. In 2021, tobacco was responsible for an estimated 28,100 deaths in Nepal, more than 75 per day, accounting for 23.7% of total deaths, making it the third highest risk factor for death and disability. Smoking also harms Nepal’s economy, costing 32,818,579,754 Nepalese rupees (more than $235,000,000 USD) every year. Nepal’s policy sets a new global standard and serves as an important model for other nations, particularly low- and middle-income countries.

For years, cigarette packaging has been a marketing tool for the tobacco industry reinforcing brand visibility and increasing the social acceptability of smoking and people who smoke. To combat this, the World Health Organization’s Framework Convention on Tobacco Control (FCTC) recommends replacing tobacco packaging with large graphic warning labels to inform users about health risks and reduce its appeal. 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 graphic warning labels 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 considerably boost the quit intentions of people who smoke, promote quitting attempts, and lessen the appeal of smoking among young people. For example, a 2021 study conducted in a region of Nepal with high illiteracy rates found that pictorial warnings that covered 90% of cigarette packs at the time, encouraged over half of the respondents to try to quit smoking. These findings underscore the potential of graphic health warnings to foster behavior change, particularly in low- and middle-income countries (LMICs), where tobacco use remains high. Nepal’s recent policy stands as one of the strongest implementations of these guidelines, showing resilience against industry interference. To date, 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. The new 100% warnings have clear, colorful images and Nepali text. The policy was introduced by the Ministry of Health and Population (MoHP) with support from public health organizations, anti-tobacco advocacy groups, and international bodies including the World Health Organization and The Union. Civil society organizations and health experts also played a crucial role in pushing for stronger regulations. The Health Promotion & Non-Communicable Disease and Tobacco Control Section under the National Health Education and Communication Center leads tobacco control efforts in Nepal. It supports the Ministry of Health and Population 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.

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 centers, and other designated public spaces, implementation remains inconsistent. 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.

Kiran Paudel, Nepal Health Frontiers, Tokha-5, Kathmandu Nepal, Department of Allied Health Sciences, University of Connecticut, CT, USA kiranpaudel59@gmail.com

Kamal Gautam, Rethink Lab, Kathmandu, Nepal, Department of Allied Health Sciences, University of Connecticut, CT, USA

Sangam Shah, Tribhuwan University, Institute of Medicine, Kathmandu, Nepal

Roman Shrestha, Nepal Health Frontiers, Tokha-5, Kathmandu Nepal, Department of Allied Health Sciences, University of Connecticut, CT, USA