Pictorial Health Warning

Tara Singh Bam

Regional Advisor Tobacco Control The Union Asia Pacific, Singapore

tsbam@theunion.org

Cost-effective interventions are needed

We know:

There are only two ways to reduce tobacco use: prevent youth from starting to use tobacco and encourage and help users to quit

Pictorial Health Warnings are effective To convince smokers to quit smoking

To convince youth not to start smoking

To re-convince ex-smokers to remain smokefree

To build public awareness

A journey of Pictorial Health Warnings-challenging but successful

Text

Injurious to health

2009 2010

30% PHW

2011 April 2014

75%

PHW

?Adopted a

comprehensive

TC law in 2011

Government

regulation

(never

implemented)

Enforcement

Taking risks

2011- Litigation: Industrys claims

75% PHW is against WHO FCTC Against Consumers protection law, Excise Law

25% space on the pack is not sufficient enough for trademark and other information

The provision of 75% PHW is not constitutional

6 months is not sufficient; 18 months is needed

Source: Supreme Court Verdict No. 068-wo-0383, page

12/25

29 December 2013- Final verdict of the Supreme Court

It has been proven that tobacco use is harmful and threatens the populations health and right to health.

It is the states responsibility to protect health and the right to health.

The Tobacco Control Law of 2011 adapts constitutional provisions, established principles of the Supreme Court, WHO FCTC and other international treaties on human and social rights.

The Supreme Court orders the government to effectively enforce the law beginning immediately and remove all tobacco products from the market that do not comply with the law.

Source: Supreme Court Verdict No. 068-wo-

0383, page 25/25

Enforcement of PHW

April 2014

Do Pictorial Health Warning work?

Conducted a national survey to assess peoples opinions, retailers views, and implementation status from JanuaryFeb 2015

2,250 individuals were randomly selected from 9 districts representing all five regions in Nepal

The study was conducted by Civil Society Action Nepal. Ethical clearance was obtained from Nepal Health Research Council

Results from Public Opinion Survey

Did you notice PHW on cigarette packs? 93.8% noticed PHW on cigarette packs in the last 30

days (current smokers 99.3%, ex-smokers 95.9%, never smokers 90.9%)

90.3% said PHW made them think about the harms of smoking (current smokers 82.1%, ex-smokers 96.2%, never smokers 93.7%)

Total N = 2250, Noticed 2110, current smokers = 670, ex-smokers = 193, Never smokers = 1387

Do you support PHWs on cigarette packs?

Total N = 2250, current smokers = 670, ex-smokers = 193, Never smokers = 1387

How worried do you feel when you see PHW on a pack?

Total N = 2250, current smokers = 670, ex-smokers = 193, Never smokers = 1387

How effective would PHW be in convincing smokers to quit smoking?

Total N = 2250, current smokers = 670, ex-smokers = 193, Never smokers = 1387

Did PHW make you consider quitting (only for smokers) ?

Total N = 2250, current smokers = 670

PHW made about 55% of the current smokers consider quitting

Did PHW make you reduce the number of cigarettes smoked?

Yes; 45.5% of current smokers reduced the amount of cigarettes smoked

On average, the number of cigarettes smoked per day reduced to 5 sticks from 11 sticks due to PHW

Before PHW = 11 cigarettes/day After PHW = 5 cigarettes/day

Average money spent on

cigarettes/day = Rs. 50.7

(USD. 0.51)

Average amount spent on

cigarettes/day = Rs. 102.6

(USD. 1.02)

PHW reduces consumption and saves out-of-pocket expenditure

How effective are PHW in convincing youth not to start smoking?

Total N = 2250, Adult = 431, Young Adult = 1255, Youth= 564

About 90% of youth said PHW would be effective in preventing initiation

How effective are PHW in re-convincing ex-smokers remain quitter?

Total N = 2250, current smokers = 670, ex-smokers = 193, Never smokers = 1387

More than 95% of ex-smokers said PHW would be effective in re-

convincing ex-smokers to remain quitter

How effective PHW in informing people on danger of tobacco use?

Total N = 2250, Male= 1717, Female= 533

More than 90% of the respondents said PHWs would be effective in building

public awareness

Do you still buy cigarette packs without PHW?

Yes, Still buy cigarette packs without PHW, 0.4% (n=3)

No, not available in the market 99.6% (n=667)

Total N = 2250, current smokers = 670,

PHW is effective in controlling illicit trade

Results from Retailers opinion survey

Retailers opinion on PHW (N=270)Questions/statement Yes (%) No

Do you support PHW regulation that aims to make people aware of the dangers of smoking?

250(92.6)

20 (7.4)

Is there any decline in cigarette sales because of PHW?

95 (35.2)

175 (64.8)

Do smokers prefer to buy cigarette pack without PHW?

172 (63.7)

98 (36.3)

Do you still sell cigarettes without PHW? 6 (2.2)

264 (97.8)

Do you still receive cigarette packs without PHW from distributors or manufactures?

2 (0.7)

268 (99.3)

Results from point of sale observation

Observation at point of sale (N=270)

Of the 270 point of sale (POS);

96.3% (260) observed all packs with PHW

3% (8) observed >90% packs with PHW

0.4% (1) observed >50% packs with PHW

0.4% (1) observed all packs without PHW

Tobacco industrys interference at point of sale

Buy 3

cigarettes for

Rs. 10

Did you buy a pack of cigarettes or loose/sticks during your last purchase?

Total N = 2250, current smokers = 670

Reasons for buying loose cigarettes

23.3% (122) of current smokers said they did not have sufficient money to buy a pack of cigarettes

66.2% (346) of current smokers said they do not like to regularly see lung cancer pictures on packs

10.5% (55) of current smokers cited other reasons

Evidence: know share - ACT?

Ministry of Health- Action taken

2015- Nepal adopted a new TC regulation

Bans selling loose/single sticks

Makes it mandatory for a pack of cigarettes to contain at least 20 sticks

Bans TI interference (adoption of Article 5.3)

Bans e-cigarettes, shisha, cigars

Nepal increased size of PHW from 75% to 90%

Enforcement of a 90% pictorial health warning on 15 May 2015

Some obstacles from

- US Chamber of Commerce

- Tobacco Industry Litigation

National Commitment

We know we have won

90% 75%

Pictorial Health Warning in Indonesia

Pictorial Health Warning in Indonesia

Government Implementation Regulation (PP109/2012) and Ministerial decree number 28/2013 mandate a 40%PHW with text consisting of 5 (five) different images

Implemented on 24 June 2014

Survey methods

The survey was conducted in February 2015

5409 people were randomly selected from 18 cities/districts representing 13 provinces in Indonesia (54 respondents were excluded from the analysis because of the missing information for many variables)

1429 points of sale (POS) were observed and 1425 retailers were interviewed

557 packs of cigarettes from 160 brands were assessed to monitor compliance

Ethical clearance was obtained from Univ. Airlangga , Surabaya

Results:

Public opinion regarding the effectiveness of PHW

Did you see PHW on cigarette packs?

94.3% noticed PHW on cigarette packs in the last 30 days (current smokers 96.9%, ex-smokers 94.6%, never smokers 92.5%)

83.9% of the respondents said PHW made them think about the harms of smoking (current smokers 70.8%, ex-smokers 87.2%, never smokers 92.4%)

Total N = 5355, tahu PHW 5038, perokok = 1898, mantan perokok = 553, bukan perokok = 2892

Do you support pictorial health warning on cigarette pack?

Total N = 5355, Smoker = 1901, Ex Smoker = 555, Non Smoker = 2899,

How effective would PHW be in convincing smokers to quit smoking?

Total N = 5355, Smoker = 1901, Ex Smoker= 555, Non Smoker= 2899,

How effective would PHW be in re-convincing ex-smokers to remain smokefree?

Total N = 5355, Smoker= 1901, Ex Smoker= 555, Non Smoker= 2899,

How effective would PHW be in convincing youth not to start smoking (by age group)?

Total N = 5355, Youth (12-17 ) = 1580, Young-Adult (18-35) = 2823, Adult (>35) = 925

Did PHW on cigarette packs make you consider quitting?

Total N = 5355, Smoker = 1901

Smokers only

Did PHW make you reduce the number of cigarettes smoked per day?Before and after viewing PHW on cigarette packs

n = 515 current smokers

Do you support the government in increasing the size of PHW to 75% from the current 40%?

Total N = 5355, current Smoker = 1893, Ex-smoker= 554, Never Smoker= 2843, No response= 65

Retailers opinion on PHW (N= 1425)

Questions Yes (%) No No response

Do you support PHW regulation that aims to make people aware of the harms of smoking?

1205(84.6)

220 (15.4)

0(0)

Is there any decline of cigarette sales because of PHW?

315 (22.1)

1109(77.8)

1(0.1)

Do smokers prefer to buy cigarettes without PHW ?

807 (56.6)

613 (43.0)

5(0.4)

Do smokers prefer to buy loose or single cigarette ?

507(35.6)

913(64.1)

5(0.4)

Do you still sell cigarettes without PHW ? 306 (21.5)

1110 (77.9)

9(0.6)

Do you still receive cigarette packs without PHW from distributors or manufactures?

142 (10.0)

1272 (89.3)

11(0.8)

Observation at point of sale (N=1429)

Of the 1429 Points of Sale (POS):

72.1% (1030) observed all packs (100%) with PHW

21.1% (301) observed >90% packs with PHW

3.4% (49) observed >50% packs with PHW

0.6% (8) observed all packs without PHW

Conclusions PHW were found effective in building public awareness both in

Nepal and Indonesia

Larger PHW encourage current smokers to quit as demonstrated in Nepal (54.8%) vs. Indonesia (47.7%)

PHW motivates current smokers to reduce the number of cigarettes smoked per day

Both the public and retailers strongly support PHW

PHW was found to be an effective intervention in eliminating illicit trade

Effective implementation of PHW has encouraged MOH in both countries to increase PHW size: In Nepal, PHW has already increased from 75% to 90%

In Indonesia, MOH plans to increase PHW from 40% to 75%