The U.S. is late to the game on graphic cigarette packaging.

Many countries around the world have adopted some form of large, graphic warning on cigarette packages to discourage smoking, including Canada, Australia, Thailand and members of the European Union.

The Food and Drug Administration last week released a proposed rule that would add images and larger warnings to cigarette packages and advertisements. The federal government has tried this before, but it was stopped in court after tobacco companies said it infringed upon their free speech rights.

Research supports the idea that large images and warnings make cigarettes less appealing and they can lead to smokers quitting and potential smokers never starting. 

For example, Canada implemented plain packaging and graphic warning labels on cigarette packs in 2001. Based on the Canadian government’s most recent tobacco survey, the percentage of smokers in the country dropped from 25% to 16% of the population between 1999 and 2012. 

Australia was an early adopter of packaging with graphic warning labels. Its adult daily smoking rate fell from 22.3% in 2001 to 14.7% in 2015. 

Meanwhile, the U.S. adult smoking rate in 2017 was 14%, down from 20.9% in 2005, according to the Centers for Disease Control and Prevention.

The U.S. warning on cigarette packages hasn’t changed since 1984, when the black-and-white, text-only surgeon general’s warning was implemented. In its proposed rule, the FDA introduced 13 cigarette health warnings that would appear on packages, as well as suggested images to go with them.

For example: “‘WARNING: Smoking causes COPD, a lung disease that can be fatal’ paired with a concordant, factually accurate, photorealistic image depicting COPD. The image shows gloved hands holding a pair of diseased, darkened lungs removed from a smoker with COPD,” the proposed rule reads.

The rule is open to public comment until October 15.