Introduction:
Aim: This study aimed to: (1) describe current packaging and labeling requirements in all 53 countries of the World Health Organization (WHO) European Region (ER) according to Article 11 Guidelines of the WHO Framework Convention on Tobacco Control (FCTC), and (2) assess the improvement of health warning labels (HWLs) since adoption of the Guidelines in 2008.

Methods:
We analyzed over 625 pieces of legislation from the WHO ER in Tobacco Control Laws (www.tobaccocontrollaws.org), a database of the International Legal Consortium at the Campaign for Tobacco-Free Kids. Additionally, we reviewed the 2017 WHO MPOWER Report. We assessed HWL type (text-only vs. pictorial), size (% of the principal display areas, PDAs), and the adoption of standardized packaging.

Results:
As of January 21, 2018, 2 countries have no laws requiring HWLs; 6 require text-only HWLs of at least 30%; 5 require pictorial HWLs of less than 50%; 39 require pictorial HWLs of 50-74%; and 1 requires pictorial HWLs of 75%. Since adoption of the Guidelines, the number of countries requiring text-only HWLs on at least 30% of PDAs has decreased from 35 to 6; countries with pictorial HWLs on 30-49% of PDAs have decreased from 6 to 5; countries with pictorial HWLs on 50-74% of PDAs have jumped from none to 39; and 1 country has passed a law requiring pictorial HWLs on 75% of PDAs. Following Australia's example, 5 European countries (United Kingdom, France, Hungary, Norway, and Ireland) have adopted standardized packaging. Georgia and Slovenia have adopted legislation but the laws are not yet in force.

Conclusions:
Adoption of the Guidelines contributed to an increase in effective HWLs in the WHO ER. In addition, two regional economic bodies – the European Union (through the Tobacco Products Directive 2014/40/EU) and the Eurasian Economic Commission –prompted their member states to adopt more effective HWLs.

Funding:
The study was supported by the Bloomberg Initiative to Reduce Tobacco Use.