Recent Findings from the ITC Project on the Effectiveness of Health Warnings in the Asia Pacific Region

Transcription

1 Recent Findings from the ITC Project on the Effectiveness of Health Warnings in the Asia Pacific Region Geoffrey T. Fong, Ph.D. University of Waterloo and Ontario Institute for Cancer Research Tobacco Control Workshop Taipei, Taiwan September 16,

2 Some Statistics on Global Tobacco Use billion people smoke 82% live in low-and middle-income countries 500 million will die of tobacco-related causes 20th Century: 100 million tobacco-related deaths 21st Century: 1 billion tobacco-related deaths About 5.4 million will die this year (and another 600K will die of secondhand smoke) By 2030: 8 million will die/year WHO: Tobacco use is the leading preventable cause of death and disability in the world

3 Chronic Diseases Infectious Diseases Extreme Weather Terrorism

4 Tobacco is the most effective agent of death ever developed and deployed on a worldwide scale. John Seffrin, Past President, American Cancer Society and the International Union Against Cancer Tobacco use is unlike other threats to global health. Infectious diseases do not employ multinational public relations firms. There are no front groups to promote the spread of cholera. Mosquitoes have no lobbyists. WHO Zeltner Report (2000) 4

5 Framework Convention on Tobacco Control (FCTC) First-ever health treaty Unanimously adopted in nations have become Parties to the FCTC Obligates parties to implement strong tobacco control policies: Graphic warnings Ad/Promo/Marketing Bans Higher taxes to raise price Smoke-free laws Support for cessation Reduction of illicit trade No industry involvement

6 ITC Evaluation of FCTC Policies (Partial List) Warning labels UK (2003): Text India (2009): Graphic UK (2009): Graphic Thailand (2005, 2006, 2010): Graphic Australia (2006): Graphic Canada (2010): Graphic, Round 2 China (2008): Text Mexico (2008): Graphic Uruguay (2006,09): Graphic Brazil (2008/09): Graphic, Round 3 Malaysia (2008): Graphic Mauritius (2009): Graphic New Zealand (2008): Graphic Taxation All countries Product policies UK (EU): regulation US/Canada: Reduced ignition propensity All countries: product; product x behavior Light/mild bans Illicit trade China (2008): prevalence Additional in Canada/U.S.: close to reserves Bhutan (2009+): total ban on sales in country Advertising/Promotion UK (2003): Comprehensive Canada (2003): Last part of Comp. Thailand (2006): POS bans Mexico (2008): Comprehensive Canada (2008+): Re-emergence of descriptive ads & possible new ban China (2011): Comprehensive Many other countries: Partial Smoke-free Ireland (2004) Mexico (2008+) Scotland (2005) Brazil (2008+) England (2007) Bangladesh (2009+) Uruguay (2006) Bhutan (2009+) France (2007/08) India (partial) Germany (2008+) Mauritius (2009) China (2008/09 + Olympics) Netherlands (Part /09) UK (2003) Australia (2005) Canada (2006) Brazil + others (2009+) 6

7 Outline ITC findings from the Asia-Pacific Region: Australia, New Zealand, Republic of Korea, Thailand, Malaysia, China India findings were just released at the Endgame Conference in Delhi (Sept 2013) Comparison of pictorial warnings with text What has happened in those countries that have not introduced pictorial warnings? (Korea, China) Looking to the future

8 Health Warning Labels 8

9 Warning Labels are Important for Tobacco Control Warning labels are highly effective for increasing knowledge Average smoker in China smokes 17 cigarettes per day. 17 x 365 = 6,205 possible exposures per year! Adding graphic images of specific harms and diseases caused by smoking increase effectiveness of warnings. Warning labels: a very low-cost tobacco control policy.

10 Measures of Effectiveness for Health Warnings

11 New Zealand: February 2008 (30% front, 90% back) Noticing pre= 49.3% Noticing post= 67.3% Increase of 18.0% Forgoing cig pre = 10.9% Forgoing cig post = 15.8% Increase of 4.9% 650,000 smokers in New Zealand After the introduction of pictorial warnings: 117,000 more smokers noticed the warnings 30,550 more smokers reported forgoing a cigarette because of the warnings

12 Australia: March 2006 (30% front, 90% back) Noticing pre = 43% Noticing post = 72% Increase of 29% Forgoing cig pre = 10% Forgoing cig post = 21% Increase of 11% 3 million smokers in Australia: After the introduction of pictorial warnings: 870,000 more smokers noticed the warnings 330,000 more smokers reported forgoing a cigarette because of the warnings But note the wearout after Wave 5

13 Malaysia: June 2009 (40% front, 60% back) June 2009 From Text on Side to pictorial warnings: 40% of front, 60% on back Noticing pre = 51.4% Noticing post = 67.2% Increase of 15.8% Forgoing cig pre = 21.2% Forgoing cig post = 54.6% Increase of 33.4% 3.6 million smokers in Malaysia After the introduction of pictorial warnings: 569,000 more smokers noticed the warnings 1,202,400 more smokers reported forgoing a cigarette because of the warnings

14 Thailand: 3 rounds of pictorial warnings March 2005: 50% of front, 50% of back

15 Thailand: 3 rounds of pictorial warnings March 2007: 50% of front, 50% of back March 2010: 55% of front, 55% of back

16 Thailand: 3 rounds of pictorial warnings Noticing at Wave 1 = 63.0% Noticing at Wave 5 = 84.6% Increase of 21.6% Forgoing cig at Wave 1 = 45.7% Forgoing cig post = 62.8% Increase of 17.1% About 13 million smokers in Thailand After 3 rounds of pictorial warnings: 2.81 million more smokers noticed the warnings 2.22 million more smokers reported forgoing a cigarette because of the warnings And little sign of wear-out over the 5 waves

17 South Korea: (30% text only and NO changes) Noticing at Wave 1 = 41.9% Noticing at Wave 3 = 36.1% DECREASE of 5.8% Forgoing cig at Wave 1 = 15.9% Forgoing cig at Wave 3 = 8.4% DECREASE of 7.5% About 20 million smokers in Republic of Korea: 1.16 million FEWER smokers noticed the warnings 1.50 million FEWER smokers reported forgoing a cigarette because of the warnings

18 ...then there s China... 18

19 China s warning labels changed in Oct 2008 OLD warning: Side of pack Only one message NEW warnings: Front/back of pack Two messages

20 China s warning labels changed in Oct 2008 Warnings appear in English on the back of every pack

21 ITC Evaluation of the Oct 2008 Text-Only Revision Noticing pre = 41.8% Noticing post = 44.6% Increase of 2.8% Forgoing cig pre = 16.8% Forgoing cig post = 22.1% Increase of 5.3% About 300 million smokers in China: 8.4 million more smokers noticed the warnings 15.9 million more smokers reported forgoing a cigarette because of the warnings Because of the enormous sample size, all of the small increases seen here are statistically significant except for avoiding 21

22 ...However, suppose China had implemented pictorial warnings... 22

23 If China implemented Malaysia s graphic warnings... Noticing warnings Warnings made them think about quitting Avoided warnings Warnings made them forgo a cigarette 8.4 million more smokers 47.1 million more Net gain = 39 million 15.9 million more smokers 98.1 million more Net gain = 82 million 23

24 Second text-only revision in April Increased the font size 2. Replaced the English with Chinese on the back 3. Everything else remains the same 24

25 Oct 2008 to Mar 2012 From Apr

26 Male cigarette smokers opinions on whether there should be more, less, or the same amount of health information on cigarette packages, by country BUT Chinese smokers are SUPPORTIVE of stronger warnings: 41% want MORE information on cigarette packs; only 6% want less information

27 ITC Project s Report on Wave 1 of the TCP India Survey 27

28 Warning Labels Made Smokers Think About the Health Risks of Smoking As with the other measures: enormous variability across states (4% in MH to 24% in Bihar) Maharashtra is second lowest among ITC countries/ jurisdictions.

29 Warning Labels Made Smokers Think About the Health Risks of Smoking As with the other measures: enormous variability across states (4% in MH to 24% in Bihar) Maharashtra is second lowest among ITC countries/ jurisdictions.

30 Male smokers opinions about whether cigarette packages should have more, less, or the same amount of health information as they do now: The percentage of smokers wanting more information on packs is highest in India (58-82%) and in Bangladesh (79%)

31 Percentage of Male Smokers Who Want MORE Health Information on Packs 100% 80% 60% 40% 20% The percentage of smokers wanting more health information on packs is highest in India (58-82%) and in Bangladesh (79%). Indian smokers themselves want STRONGER and more informative warnings BH WB MP MH India 58 82% Bangladesh 79%

32 Taiwan s pictorial warnings 32

33 Looking Ahead: Other models for warnings Canada 33

34 Why the ISO Testing Method is Invalid as a Method for Assessing Health Harm The ISO/FTC protocol is set at much lower puff volumes and less frequent puffs than the average smoker Tobacco companies have deliberately designed light brands to defeat the ISO smoking machine Filter vent holes let air through Vent holes sit outside the ISO machine port so smoke is diluted Smokers compensate to get the nicotine dose they need (puffing harder/deeper; covering vent holes) Result: ISO ratings are invalid; lights are NOT less harmful 34

35 Light/Low-Tar Cigarettes Light cigarettes are believed by smokers to be less harmful...and as either an alternative to quitting or a step toward quitting 35

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40 Looking Ahead: Other models for warnings Canada 40

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42 Health Information Messages 42

43 New Content 43

44 Different way of presenting the harm 44

45 Focusing on the human tragedy of cigarette use 45

46 US CDC Campaign: Tips from Former Smokers 46

47 US CDC Campaign: Tips from Former Smokers 47

48 Evaluation of TIPS campaign Lancet (9 Sept 2013) Pre-post cohort design 3051 smokers 2220 non-smokers 78% smokers 74% non-smokers reported seeing at least one ad Quit rates: 31.1% to 34.8% (1.64M additional smokers attempted to quit) Recommendations by nonsmokers for a smoker to quit: 2.6% to 5.1% (4.7M additional) People talking with friends & family about dangers of smoking: 31.9% to 35.2% (6.0M additional) 48

49 Inclusion of a toll-free line Important addition to the warnings. Likely to lead to (much) higher levels of use of quitlines. 49

50 Looking Ahead: Other models for warnings Australia 50

51 Australia: Plain Packaging December 2012: 75% of front, 90% of back

52 Recommendations from ITC Findings Pictorial warnings are an essential component of a comprehensive tobacco control program Strong, graphic images increase noticing and effectiveness Wear-out happens quickly (Mauritius: some effectiveness measures start to decline within 2 years): must plan ahead for revisions Location, Location, Location: front is SO much better than the back. Think beyond gross images. Consider capturing the range of the human tragedy of tobacco-related diseases. Taiwan is a huge market for light/low tar cigarettes Ultimately: all roads lead to plain packaging.

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