Background:
Two agents are responsible for producing effective cigarette health warning labels (HWLs): governments ensure HWL legislation is comprehensive with clear implementing rules, and tobacco companies are responsible for implementation. We determined what factors contribute to noncompliance with HWL legislation in nine countries that improved their HWL requirements over a three-year period.

Methods:
Unique cigarette packs were purchased in 2013 (N=1164) and again in 2015-2017 (N=1413) across nine low- and middle-income countries (Bangladesh, Brazil, China, India, Indonesia, Philippines, Russia, Thailand, and Vietnam) that improved their HWL legislation. Country-specific HWL compliance codebooks were created to assess up to four HWL compliance indicators: location, label size (coverage), label elements (e.g., text or background color, borders), and text size.

Results:
HWL compliance in 2013 ranged from 17-90%; compliance in 2015-2017 ranged from 33-95%. Of the four indicators, HWL size (label coverage too small) and text size (text height too short or text and graphic content ratio incorrect) were the largest contributors to noncompliance. When the HWL size requirement was removed, compliance increased from 24-100% in 2013, and 84-100% in 2015-2017. Similarly, when HWL text size was removed, compliance increased from 45-90% in 2013, and 53-95% in 2015-2017.

Conclusions:
We found that text size requirements ranged from non-existent, to simple (i.e., font size or text height requirements), to complex (i.e., specific text and graphic content ratios). The more complex requirements were oftentimes poorly specified and thus were difficult to assess for compliance. Governments could simplify text size requirements by: (1) providing minimum font or height measurements or incorporating text within the HWL as a template; and, (2) not specifying text/graphic ratios. We also found that tobacco companies are shirking their responsibility to ensure that the HWL is the minimum size required by governments. Tobacco companies should be held accountable for complying with HWL requirements.