By David I Conway and Frances E Warner
Mouth cancer is on the rise – tobacco remains the major cause and yet mouth cancer has disappeared from tobacco warnings in the United Kingdom.
Mouth (oral) cancer is a devastating disease that causes untold suffering and it is on the rise. Globally, the recent GLOBOCAN data estimates over 500,000 new cases and 210,000 deaths annually. The Oral Health Foundation recorded 10,825 mouth cancer cases and 3,637 deaths across the UK in 2024. Public Health Scotland report that survival outcomes are worsening, unlike for most other cancers. Inequalities in mouth cancer persist, both within and between countries, such that low and middle-income countries and disadvantaged populations bear the greatest disease burden.
Tobacco, smoked or smokeless is the predominant risk factor, implicated in around two-thirds of oral cancers diagnosed. Smoking cessation has been shown to reverse the risk of oral cancer with risk reductions appearing within 4 years of quitting and approaching those of never-smokers after 20 years.
Evidence is strong for the impact of health warnings on cigarette packages. However, limited attention has been given to recent changes to the graphic warning images on tobacco products in the UK. Unlike general health warnings, such as text stating “Smoking seriously harms you and others around you”, cancer warnings are condition-specific, direct and well understood for example, “Smoking causes 9 out of 10 lung cancers” – which is typically accompanied by a vivid image of a necrotic lung cancer during surgery. .
The WHO has developed a pictorial health warnings database of graphic images/photographs for use on tobacco packaging (known as a picture library). Different countries use different picture libraries on their tobacco packaging. When the UK was a part of the EU, all UK tobacco packaging used a picture library developed by the EU, which has 14 health warnings rotating annually, including mouth cancer images.
After exiting the EU, the UK was no longer allowed to use these images for copyright reasons after January 2021. We submitted a Freedom of Information request to the Department of Health and Social Care (DHSC) to understand the decisions to change the UK labelling and images. We did not find evidence that tobacco industry lobbying drove removal of the mouth cancer warnings, however, our request revealed how an important public health policy change occurred amid the turbulence of the COVID-19 pandemic and Brexit.
In 2018, the UK Government secured agreement to use a picture library developed by Australia following the UK exiting the EU. The DHSC consulted on the regulations that changed the picture library from the EU picture library to the Australian picture library between 8 and 21 October 2018, publishing a consultation response on 21 February 2019. However, the practical switch from the EU library to the Australian library only took effect after the Brexit transition period ended i.e. from 1 January 2021.
Australia’s picture-warning library, adopted in the Tobacco Products and Nicotine Inhaling Products (Amendment) (EU Exit) Regulations 2020, comprise text and images across 13 warnings, but mouth cancer is not included. These regulations cover Great Britain (England, Wales and Scotland) not the UK (England, Wales, Scotland and Northern Ireland). Under Brexit arrangements the Northern Ireland Protocol was created (subsequently the Windsor Framework), which included the EU’s Tobacco Products Directive continuing to apply in Northern Ireland. This means that Northern Ireland continues to use the EU picture library for relevant tobacco products sold there, as set out in the tobacco packaging guidance for Northern Ireland.
In Australia, public health legislation and regulations introduced in 2024 updated their tobacco graphic warnings picture library, which now includes images of mouth cancer in their suite of warnings. The Australian Government is in the process of developing new health warnings to be included on a rotating basis, and a consultation is planned for later this year.
Despite adopting the Australian guidelines, the Great Britain warnings have not been updated, and mouth cancer images are still omitted. However, on 10 July 2026, the DHSC launched a consultation on tobacco and vape packaging, appearance, and display. The consultation seeks views on the packaging of tobacco and herbal smoking products, heated tobacco devices and cigarette papers, including proposals for further plain packaging requirements, text health warnings, picture health warnings, and pack inserts in packaging. The consultation runs for 12 weeks closing on 2 October. Warning of the devastating impact of mouth cancer needs to be re-included on tobacco packaging and we strongly encourage responses in support.
Authors:
David I Conway and Frances E Warner – School of Medicine, Dentistry, and Nursing, University of Glasgow, Glasgow, UK