apply to all products sold in the country

Report of Advocacy Workshop on Warning against dangers of tobacco: Packaging and Labelling, 25-26 April, 2013, University of Public Health, Yangon, Myanmar Background According to the Article 11 of the WHO Framework Convention on Tobacco Control (FCTC) that deals with health warnings and labelling of packages, there are a few key obligations by Parties to the Convention. Effective package warnings increase awareness of the health effects of tobacco use and exposure to tobacco smoke, and decrease consumption. Deceptive labelling by the tobacco industry undermines public health objectives. Under Article 11, Parties agree to adopt regulatory measures to deal with these matters. The importance of Article 11 is underlined by the guiding principle in Article 4.1 that [e]very person should be informed of the health consequences, addictive nature and mortal threat posed by tobacco consumption. The obligations in Article 11 apply to all products sold in the country, whether imported or domestically manufactured. While the Article 11 obligations are a very important part of the FCTC, to date there has been wide variability in implementation. Although some Parties have required picture-based warnings of at least 50% in size, some other Parties have required the bare minimum of text-only warnings with the minimum size of just 30%. Some Parties have only required warnings on the back of the package, and not on the front and back. Some other Parties, subsequent to FCTC ratification, have implemented new national regulations that are not compliant with the FCTC, such as: requiring a 50% warning on either the front or back, not both (thus making the average just 25% of the front and back, less than the 30% minimum); or requiring a single message to appear on packages, instead of the required rotated series of messages. Myanmar national law - the Control of Smoking and Consumption of Tobacco Product Law (the State Peace and Development Council Law No 5/2006) adopted in May 2006, and related notifications issued by the Government of Myanmar had stipulated comprehensive bans on tobacco advertising, warn against dangers of tobacco for any packaging and labelling, promotion and sponsorship. Myanmar Ministry of Health is responsible for determining the caption of warning in Myanmar language, to be mentioned on the package of tobacco products, that smoking can seriously affect health and other necessary warnings. Up till now, all cigarette boxes contained a small print of warning in Myanmar language (in less than 5% of space). The cigarette boxes also do not mention the "origin of the product" nor "the disclosure of contents". Similarly, the packages for cheroots do not display proper labeling, health warning, or disclosure of contents. Only a handful of supermarkets showed the caption of health warning or prohibiting of sales to minors (below 18 years of age). Majority of street vendors does not know of such legislation existed and cigarettes could be purchased singly or in a package less than 20 from them. An advocacy workshop was primarily targeted at concerned officials of the Ministry of Health and related ministries responsible for regulating tobacco advertising and labelling, was 1

organized at the University of Public Health, Yangon, from 25 th to 26 th April, 2013. The workshop was organized by the People s Health Foundation, in collaboration with the Department of Health, the Society of Preventive and Social Medicine, and the University of Public Health, and with support from WHO SEARO. Objectives: a. General objective: The general objective is to increase the technical capacity of the respective government officials to implement effective policies for the packaging and labelling of tobacco products, consistent with WHO FCTC Article 11 guidelines on implementation and with international best practices. b. Specific objectives: 1. To provide workshop participants with a basic understanding of: the evidence to support requirements for warning labels on tobacco packaging and the elimination of misleading terminology from such packaging; the packaging and labelling requirements and recommendations of the WHO FCTC; the technical and legislative considerations in implementing tobacco packaging and labelling policies. 2. To provide tailored technical consultations in: promoting the need for graphic warnings and related packaging measures; developing and evaluating warnings;, and developing and accessing legislative proposals Workshop First Day (25 April 2013) The workshop is attended by an advocacy workshop, primarily targeted at concerned officials of the Ministry of Health and related ministries responsible for regulating tobacco advertising and labelling (See attached list of participants). The workshop is inaugurated by Professor Dr Nay Soe Maung, Rector of the University of Public Health, at 0900 am on 25 th April 2013 (Thursday), who also welcome all participants and invited guests. Dr U Thein Swe, Retd Director-General, Department of Traditional Medicine, and the Vice President of People s Health Foundation, gave the audience a brief explanation of the background, objectives and expected outcome of the workshop. He also thanked for WHO for its support and the Department of Health for agreeing to organize the workshop and the University of Public Health to host and make all administrative support. The participants introduced themselves. Dr U Than Sein, President of People s Health Foundation (Retd Director from WHO SEARO) provided the brief background of WHO FCTC, and the details of the Article 11, concerning the packaging and labelling requirements and the recommendations for implementation according to WHO FCTC/COP guidelines. He then elaborated overall evidence concerning the importance of packaging as a marketing tool and as a vehicle to communicate health information; the experience of many countries (including ASEAN and other developed 2

nations) in implementing packaging and labelling regulations; the evidence on the impact of health warnings and what makes health warnings most effective, as well as the impact of misleading labelling and issues related to package-based information on ingredients. Dr Nan Naing Naing Shein, Tobacco Control Unit of the Department of Health, gave a brief account on the development of Myanmar Tobacco Control Law, which was enacted in 2006, and the actions undertaken with regards to packaging and labelling for health warning against dangers of tobacco use. She stressed the action to be taken by the Ministry of Health on this issue as per Chapter 5, and the legal actions that could be undertaken under Chapter 8, on those who default on measures on health warning labelling and packaging. The percipients were then divided into 2 groups to consider the possible design and development of warnings and ingredient labelling for Myanmar. They looked at various issues, including the evidence to support plain packaging of tobacco products as an effective tobacco control measure; how to counter arguments raised by tobacco companies against effective package warnings; and the possible design of health warning messages as well as pictures that may be fit for Myanmar people. The outcomes of the group discussions are as follow: 1) It is prime time for Myanmar to develop effective health warning (messages as well as pictures) for both smoking as well as smokeless tobacco, since the smokeless tobacco is in higher usage among rural and young populations. 2) The messages and pictures should cover for all population groups, i.e., those who start smoking or use of smokeless tobacco (pan masala or betel quids), those are already regular users; and those who want to quit. 3) Messages and pictures should be of relevant to both the smoking tobacco (like cigarettes, cheroots, cigars, hookahs (Shisha), and other hand-roll cigars), and also the smokeless tobacco (chewing betel quids with different types of tobacco preparation). 4) When preparing the messages and selecting appropriate pictures, the following points have been recommended taking into consideration of actions taken by ASEAN countries, as well as other developing and developed nations: a) The messages and pictures should depict not for frightening the users but the real dangers on the use of tobacco, impact on social and economic lives of the families, and the effect on environment. b) The following health warning messages, in addition to those used by ASEAN nations like Singapore, Malaysia, Thailand and Singapore, were proposed: i. Quit smoking and healthy; ii. Tobacco kills iii. Smoking/Pan eating causes oral cancer iv. Stop smoking make family healthy v. Smoking effects family income vi. Smoking effects mother and baby vii. Smoking destroys social and physical environment c) The messages and pictures should be clear, vivid in color contrast, and fit in local customs. 5) All health facilities (both public and private) should be prepared for accepting smokers or betel-quid users for quitting their habits. 3

6) Appropriate hot-line questions and answers for tobacco use should be created. 7) Sellers of tobacco and tobacco products should abide the regulations already stipulated in the National Tobacco Law. 8) Spitting (due to eating pan masala or betel quid) at all public places should be prohibited under environmental protection and control legislation. Workshop Second Day (26 April 2013) Professor Dr Nay Win, Vice President, Myanmar Academy of Medical Sciences, chaired the second day sessions. Dr Than Sein gave the summary of discussions yesterday and also the explanation on the works to be accomplished today. The percipients were then divided into 2 groups to consider implementation of packaging and labelling policies, including the development of legislation for Myanmar. They looked at various issues including the existing gaps of Myanmar Tobacco Law, and how to develop effective package warnings; and the possible design of health warning messages as well as pictures that may be fit for Myanmar people. The outcomes of the group discussions are as follow: 1) Although Myanmar Tobacco Law has been in existence since 2006, majority of people, especially road side sellers of tobacco products and consumers, did not have any knowledge of the measures put in the law. 2) While the Law has met the requirement of WHO FCTC as completely as possible, there are still some gaps, especially in defining tobacco and tobacco products, banning smoking in public places, putting health warning messages, labels and pictures, banning advertisement and sponsorship, and measures for supply reduction. Since amendment or revision of existing legislation may take some time, it is still possible to implement effectively of existing measures promulgated under the present Tobacco Law. 3) Within the mandate given by the existing National Tobacco Law, the following notifications, announcements, ministerial orders, etc., could be issued. a) The present definition of Say Lake or Cigars includes any cigarette, cheroot, cigar (say-pyin-lake), smoking pipe (say-tan) and any other similar material prepared by any means for inhalation of smoke emitted from burning of tobacco products. Official announcement should be made that shisha (hookah) and smoking water-pipe (formerly used for smoking opium but now using for smoking tobacco, with smoke passing through water, similar mechanism for shisha), are also included by this definition, since many young people started switching cigarettes to shisha or water-pipes. b) Similarly, since pan-masala and betel quids include tobacco products in their preparation, the control measures under the National Tobacco Law should also apply to these products and preparations. Many pan-sellers do not realize that such law even existed. Appropriate notifications as well as education campaigns are required. 4) The present Myanmar Tobacco Law includes the responsibility of the Ministry of Health, to adopt appropriate health warning messages as required. Here are additional 4

suggestions to the Ministry of Health for adopting health warning messages and pictures: a) As per similar practices in the majority of ASEAN nations, Myanmar should adopt SIX rotating messages with accompanied pictures. b) The message and picture should cover the upper part of minimum 50% of space on the front and back cover of cigarette package; c) A pair of messages and pictures should be used and every 2 sets will be rotated every year. d) The adoption of the health warning messages and pictures should be carried out before effective date for ASEAN Trade Integration (i.e. 2015). e) As stipulated already in Article 13 (b) of the National Tobacco Law, 2006, to mention the ingredients of tobacco products in the packaging and labelling, the Ministry of Health, under the guidance of the Central Committee for Tobacco Control, should provide ministerial order on how the tobacco products should have a label on the ingredients of tobacco products in the packaging and labelling. f) Ministry of Health should issue ministerial order on banning misleading labelling like mild light, etc. g) Ministry of Health needs to clarify the translation of the word - 100 feet on banning sale of tobacco products around the schools, with 100 yards in English translation. The percipients were then divided into 2 groups again to consider the communication campaigns to promote packaging and labelling. They looked at various issues of why the implementation of National Tobacco Law has been in delay; how to promote the effective health warnings messages as well as pictures that may be fit for Myanmar people. The outcomes of the group discussions are as follow: 1) Multimedia campaigns are needed to educate the people about the importance of Myanmar Tobacco Law promulgated since 2006, why people are not following the measures; what could be the constraints that could be overcome easily with education campaigns. 2) Extensive training and education to all health professionals are in need to spread the measures enacted in the national Law. The training and education should targeted to those health professionals and basic health staff, who are still using tobacco products, either for smoking or eating as smokeless tobacco. 3) All media should include short education messages or stories on anti-tobacco measures, in their production, once in every 2 weeks, either in journals, magazines. Newspapers, TV commercials, etc. 4) Use various articles, stories and papers on dangers of tobacco use, how to quit, etc. should be available in each of rural libraries, and paper reading circles should be promoted at these libraries. 5) Efforts should be made to promote establishment of non-governing organizations and parliamentarian groups that would lobby for promoting tobacco control measures. 5

6) Since tobacco is dangerous food that could affect the health status of the people, a proposal has to be made for inclusion of tobacco products as harmful to human health under the National Food and Drug Law. 7) Efforts should be made to expand smoke-free places to tobacco-free places, at least to come out with actions for tobacco-free national events. Future Actions/Recommendations After considering the groups observations and recommendations, the workshop ended with the following recommendations for the Ministry of Health to consider them as the requisites for adoption of appropriate health warning messages and pictures. 1) In order to educate the people about the importance of Myanmar Tobacco Law which has been promulgated since 2006, advocacy workshops should be organized to be participated by at least 2 groups: (a) health professionals, organized through professional associations like Myanmar Medical Association, Myanmar Dental Association, Myanmar Health Assistant Association and Myanmar Nurses and Midwifery Association; and (b) multimedia professionals through respective professional associations like associations for journalists, newspapers, films, etc. 2) The following points have been recommended to the Ministry of Health, for its consideration on adopting health warning messages and pictures: a) Health warning messages and pictures should be used for both cigars and tobacco products. b) As per similar practices in the majority of ASEAN nations, Myanmar should adopt SIX rotating messages with accompanied pictures. c) The message and picture should cover the upper part of minimum 50% of space on the front and back cover of cigarette package; d) A pair of messages and pictures should be used and every 2 sets will be rotated every year. e) The adoption of the health warning messages and pictures should be carried out before effective date for ASEAN Trade Integration (i.e. 2015). f) The messages and pictures should depict not for frightening the users but the real dangers on the use of tobacco, impact on social and economic lives of the families, and the effect on environment. 3) The following points have been recommended to the Ministry of Health, for its consideration on implementation of packaging and labelling policies, including the development of legislation for Myanmar. a) As stipulated already in Article 13 (b) of the National Tobacco Law, 2006, to mention the ingredients of tobacco products in the packaging and labelling, the Ministry of Health, under the guidance of the Central Committee for Tobacco Control, should provide ministerial order on how the tobacco products should have a label on the ingredients of tobacco products in the packaging and labelling. b) Ministry of Health should issue ministerial order on banning misleading labelling like mild light, etc. 6

c) Ministry of Health needs to clarify the translation of the word - 100 feet on banning sale of tobacco products around the schools, with 100 yards in English translation. 4) Efforts should be made to promote establishment of non-governing organizations and parliamentarian groups that would lobby for promoting tobacco control measures. 5) Since tobacco is dangerous food that could affect the health status of the people, a proposal has to be made for inclusion of tobacco products as harmful to human health under the National Food and Drug Law. 6) Efforts should be made to expand smoke-free places to tobacco-free places, at least to come out with actions for tobacco-free national events. 7) Extensive training and education to all health professionals are in need to spread the measures enacted in the national Law. The training and education should targeted to those health professionals and basic health staff, who are still using tobacco products, either for smoking or eating as smokeless tobacco. 8) All media should include short education messages or stories on anti-tobacco measures, in their production, once in every 2 weeks, either in journals, magazines. Newspapers, TV commercials, etc. 9) Use various articles, stories and papers on dangers of tobacco use, how to quit, etc. should be available in each of rural libraries, and paper reading circles should be promoted at these libraries. 10) Within the mandate given by the existing National Tobacco Law, the following notifications, announcements, ministerial orders, etc., could be issued. a) The present definition of Say Lake or Cigars should include shisha (hookah) and smoking water-pipe (formerly used for smoking opium but now using for smoking tobacco, with smoke passing through water, similar mechanism for shisha), since they are used as material prepared by any means for inhalation of smoke emitted from burning of tobacco products. b) Similarly, since pan-masala and betel quids include tobacco products in their preparation, the control measures under the National Tobacco Law should also apply to these products and preparations. Many pan-sellers do not realize that such law even existed. Appropriate notifications as well as education campaigns are required. Closing Session Dr Than Sein concluded the workshop by thanking all participants and the host for involving effectively in the deliberations, and making a series of recommendations that could be useful for the Ministry of Health in adopting new health warning messages and labels in near future. 7