The U.S. Food and Drug Administration on Thursday released 13 new cautionary images to be placed on cigarette cartons, featuring grisly amputated limbs and underweight infants. These new images come nine years after the FDA first proposed images be added to cigarette packaging before backing down after a lawsuit brought by some of the nation’s biggest cigarette manufacturers.

The images “stand to represent the most significant change to cigarette labels in 35 years,” the FDA said in a press release. While the U.S. was the first nation to require warnings on cigarettes, they haven’t been updated in more than 30 years.

In 2016, public health groups including the American Cancer Society and the American Lung Association sued the FDA for taking too long to revise the labels. A federal court ruled in their favor saying the department had “unreasonably delayed,” and set a deadline of Thursday, Aug. 15, 2019 for the FDA to issue a draft of the images, with March 15, 2020 as a deadline for a final decision. Roughly 480,000 Americans die from smoking-related illnesses annually, according to the Centers for Disease Control and Prevention.