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 Warningschallenging but successful

75%
PHW

30%
PHW

2009
Text
Injurious to health

Taking risks

2010
Government
regulation
(never
implemented)

April 2014

2011
Adopted a
comprehensive
TC law in 2011

Enforcement

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-wo0383, 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) ?
PHW made about 55% of the current smokers consider quitting

Total N = 2250, current smokers = 670

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

Average amount spent on

cigarettes/day = Rs. 102.6
(USD. 1.02)

After PHW = 5 cigarettes/day

Average money spent on

cigarettes/day = Rs. 50.7
(USD. 0.51)

PHW reduces consumption and saves out-of-pocket expenditure

How effective are PHW in convincing

youth not to start smoking?

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

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

How effective are PHW in re-convincing exsmokers remain quitter?

More than 95% of ex-smokers said PHW would be effective in reconvincing ex-smokers to remain quitter

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

How effective PHW in informing people on

danger of tobacco use?
More than 90% of the respondents said PHWs would be effective in building
public awareness

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

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)

PHW is effective in controlling illicit trade

Total N = 2250, current smokers = 670,

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
National Commitment

90%
Some obstacles from
- US Chamber of Commerce
- Tobacco Industry Litigation

75%

We know we have won

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?
Smokers only

Total N = 5355, Smoker = 1901

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%