Background:
Of the 14 low- and middle-income countries with the greatest number of smokers, nine countries implemented improved packaging laws between 2015 and 2017. Using the Framework Convention on Tobacco Control (FCTC) as a global benchmark, we compared in-country legislation from nine countries with Article 11 recommendations, assessed unique cigarette packs against the FCTC, and identified areas for improvement in country level tobacco packaging legislation.

Methods:
We purchased unique cigarette packs according to a systematic protocol from 12 economically diverse neighborhoods within three of the largest cities within each of the countries. Country specific Health Warning Label (HWL) codebooks were created. Coding was completed by two independent coders. FCTC Article 11 was analyzed with respect to in-country legislation, with recommendations for tobacco packaging being identified. Four recommendations were used to create indicators by which HWL legislation was scored: HWL coverage >=50%; HWL positioned at the top of the principal display area; presence of graphic HWL; and qualitative statements on constituents and emissions.

Results:
Overall cigarette pack HWL compliance with in-country legislation ranged from 53% in India to 95% in Russia. In-country legislation was scored against FCTC recommendations from 0-4. HWL compliance had a strong negative correlation (-0.77) with FCTC score. In general, HWL compliance was higher for countries with lower FCTC scores. We will report detailed FCTC analysis by country.

Conclusions:
Although these nine countries have improved their HWL requirements, most still do not meet the floor set by the FCTC. We will discuss how HWL comprehensiveness, as measured by FCTC impacts overall HWL compliance. Our discussion suggests there are still multiple areas of improvement fourteen years after the FCTC was adopted. It is incumbent on governments to continue to improve HWL legislation, above and beyond the FCTC. Future legislation must be clear, comprehensive and easily implemented to ensure enforcement.