Findings from the International Tobacco Control Policy Evaluation Project (the ITC Project) in China Geoffrey T. Fong, Ph.D. Department of Psychology University of Waterloo and Ontario Institute for Cancer Research Chinese Association on Tobacco Control (CATC) Board Workshop, Beijing, China June 19, 2010 1
Tobacco Use and World Statistics 1.1 1.3 billion people use tobacco, over 80% in developing countries China: over 300 million smokers (close to 60% of men) About 5 million people die per year of tobacco-related diseases 20 th Century: 100 million people died of tobacco use 21 st Century: Up to 1 billion people may die WHO: Tobacco use is the number one preventable cause of death and disability in the world 2
Summary of the Basic Problem 1.1 1.3 billion people use tobacco, and 1/3 to 1/2 of regular smokers will die of a smoking-related disease, at an average loss of 7-10 years of life. Close to 100,000 people (mostly youth) start smoking every day Prevention of smoking is too ineffective and limited to be a dominant approach WHAT CAN WE DO? 3
The Basic Principles of the Approach Primary prevention is primary! Interventions must be carried out at the level of entire populations. Total population impact = REACH x EFFECTIVENESS These interventions must be based on understanding how to change behaviour Governments have the power and responsibility to create these population-level interventions in the form of tobacco control policies and programs 4
Potential of Policies to Flatten the Curve Tobacco deaths (millions) 500 400 300 200 100 Estimated cumulative tobacco deaths 1950-2050 220 190 520 500 340 Impact of policies depends on two main factors: 1. Intervention date 2. Effect size 70 0 1950 2000 Year 2025 2050 World Bank. Curbing the epidemic: Governments and the economics of tobacco control. World Bank Publications, 1999. p80. 5
Framework Convention on Tobacco Control (FCTC) First-ever health treaty Unanimously adopted in 2003 168 nations have become Parties to the FCTC Conferences of the Parties: COP-1: Feb 2006 in Geneva COP-2: July 2007 in Bangkok COP-3: Nov 2008 in S. Africa 6
Policies of the FCTC More prominent warning labels Elimination of light/mild and other deceptions Bans/restrictions on advertising, promotion, sponsorship Protection from exposure to tobacco smoke Higher taxes Support for cessation Education, communication, public awareness Reduce illicit trade 7
The FCTC: World s First Health Treaty Are these policies working? Do pictorial warnings work better than text warnings? Are smoke-free laws being obeyed? What factors explain why these laws may have stronger impact in one country than in others? Does policy impact vary across different people (do higher taxes have stronger impact on youth?) WHY and HOW do policies have their impact? To answer these questions, we need to evaluate FCTC policies across different countries 8
Article 11 Warnings and messages should be 50% or more of the principal display areas but shall be no less than 30%... may be in the form of or include pictures or pictograms shall contain information on relevant constituents and emissions Each Party shall, within a period of three years after entry into force of this Convention for that Party, adopt and implement, in accordance with its national law, effective measures... What does effective mean? Does size matter? Are graphic images effective? 9
Model for evaluating FCTC policies An international system for measuring: (1) basic tobacco use behaviours; (2) FCTC policy-relevant variables Common measures selected from a strong, theorydriven perspective Common research designs and methods Selecting countries to evaluate policy via natural experiments Surveillance of tobacco use behaviours and linking them to policy-relevant variables over time. 10
The International Tobacco Control Policy Evaluation Project (the ITC Project) Canada United States Australia United Kingdom Ireland Thailand Malaysia South Korea China Uruguay Mexico New Zealand France Germany Netherlands Bangladesh Brazil Mauritius Bhutan India 11
Objectives of the ITC Project Surveillance of key tobacco behaviors, psychosocial variables, and policy-relevant variables over time Evaluation of tobacco control (FCTC) policies (and other population-level interventions and programs) Dissemination of research findings to policymakers, researchers, and tobacco control stakeholders Capacity-building for researchers, policymakers, and tobacco control community 12
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ITC Surveys are being conducted in: Over 50% of the world s population Over 60% of the world s smokers Over 70% of the world s tobacco users 14 14
ITC Evaluation of FCTC Policies (Partial List) Warning labels UK (2003): Text Mauritius (2009): Graphic UK (2009): Graphic Thailand (2006): 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 India (2009): Graphic Taxation All countries Product policies UK (EU): 10-1-10 regulation US/Canada: Reduced ignition propensity All countries: product; product x behavior 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 (2007/08+) China (partial in 2008+ & Olympics) Netherlands (Part 2 2008/09) Light/mild bans UK (2003) Australia (2005) Canada (2006) Brazil + others (2009+) 15
Content of the ITC Surveys Surveillance content Mixed Surveillance and policy content Unique ITC Content: 170-200 Qs focusing on policy impact Throughout the policy sections there are measures relevant to monitoring Surveillance content 16
Warning Labels in China: Findings from the ITC Project 17
The Importance of Package Warnings/Labelling Package warnings: an excellent method for informing people about the harms of tobacco use and of smoke constituents and to motivate quitting Package warnings = a health information intervention: Smoker who smokes 20 cigarettes/day: 1. Potentially exposed 7,300 times/year to the warnings 2. Exposed at the right situations: When buying cigarettes When getting a cigarette out of the pack There are probably NO other interventions in health that are delivered so often and in such an appropriate way. 18
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Guidelines for Implementation of Article 11 1. Should appear on both front and back 2. Should be at the TOP of the package 3. Should be as large as possible (at least 50%) 4. Should include full colour pictures 5. Should rotate multiple messages 6. Should include a range of warnings and messages 7. Should include info on harmful effects of tobacco smoke 8. Should provide advice about cessation 9. Should list constituents, but NO numbers just qualitative statements about the harms 20
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Warning Labels in China: Findings from the ITC Project 22
ITC China Project Collaboration between the ITC Project and the Chinese Office of Tobacco Control (China CDC) Cohort survey in 7 cities: Beijing, Shanghai, Changsha, Guangzhou, Yinchuan, Shenyang, Kunming Total N = 5,600 smokers + 1,400 non-smokers Wave 1: May Nov 2006 Wave 2: Nov 2007 Mar 2008 Wave 3: May Oct 2009 23
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Noticing warning labels China is close to the bottom of 16 ITC countries in warning label salience 27 27
Warning labels: think about health risks Only 6.9% of Chinese smokers say that the warning labels make them think of the health risks of smoking a lot 28 28
Comparing Health Warnings in China to Health Warnings in Other Countries: An experimental study in four Chinese cities Geoffrey T. Fong, David Hammond, Pete Driezen, & Anne C.K. Quah University of Waterloo Jiang Yuan and Li Qiang China Center for Disease Control and Prevention gfong@uwaterloo.ca http://www.itcproject.org 29
China s warning labels changed in Oct 2008 OLD warning: Side of pack Only one message NEW warnings: Front/back of pack Two messages 30
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Participants The study was conducted in four cities in China: Beijing, Shanghai, Kunming, and Yinchuan. In each city, there were close to 300 participants. The total number of participants by type in each of the 4 cities was: Adult Adult Youth Smoker Non-Smoker (13-17 years) TOTAL City Male Female Male Female Male Female Beijing 55 40 39 47 51 45 277 Kunming 50 50 46 50 50 50 296 Shanghai 51 52 47 50 50 50 300 Yinchuan 50 48 48 50 50 50 296 TOTALS 206 190 180 197 201 195 1169 Within each of the adult categories, the participants were approximately evenly distributed across ages: (a) 18-29 years old, (b) 30-39 years old, (c) 40-49 years old, (d) 50+ years old. 33
The full layout of the design: 2 x 4 + China Canadian Lung Cancer Singapore Mouth Disease Hong Kong Gangrene EU Clogged Arteries and China Text Only 2 6 3 10 5 Text + Picture 9 8 1 4 7 Numbers = randomized order of the warnings 34
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The Role of Emotions in Label Effectiveness Hypothesis: graphic warning labels are more effective because they create emotions that are: Highly negative (valence is negative) Highly arousing (arousal is high) There is strong research from neuropsychological studies in social psychology to support this hypothesis. 37
Brazil s New Warnings 38
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China Labels Study: Label Effectiveness Average within subject correlation between VALENCE and... Rated effectiveness in motivating smokers to quit: r = +.45 Rated effectiveness in convincing youth not to start: r = +.46 Average within subject correlation between AROUSAL and... Rated effectiveness in motivating smokers to quit: r = +.49 Rated effectiveness in convincing youth not to start: r = +.49 Strong support for the hypothesis that label effectiveness is linked to negative valence and high arousal 41
Summary Table of the New Chinese Warnings Guideline YES NO 1 Should appear on both front and back? 2 Should be at the TOP of the package 3 Should be as large as possible (at least 50%) 4 Should include full colour pictures 5 Should rotate multiple messages 6 Should include a range of warnings and messages 7 Should include info on harmful effects of tobacco smoke 8 Should provide advice about cessation 9 Should list constituents without numbers 42
China warnings will be more effective if they... Follow the Article 11 Guidelines include images that are very negative and highly arousing include concrete information about the effects of smoking: cigarettes CAUSE cancer ; cigarettes CAUSE COPD include some NEW information about what cigarettes do: NOT just lung cancer, but heart disease, stroke, COPD, impotence, etc. include information about the effects of secondhand smoke: smoking doesn t just affect the smoker, but others as well include information that helps them with quitting and/or tells them where they can get help (although China has very limited resources for cessation) 43
World No Tobacco Day 2009 The ITC Project released a report on pictorial warnings for World No Tobacco Day (May 31, 2009): 12 page report on ITC Project findings in the domain of warning labels (in English and Chinese) 44
World No Tobacco Day 2009 45
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Light, Mild, and other deceptive brand descriptors (Article 11) Findings from the ITC Project 47
About Light or Mild Cigarettes 48
Beliefs About light/mild cigarettes Smokers believe light/mild cigarettes to be less harmful that they have less tar. 49
Beliefs About light/mild cigarettes Smokers believe that smoking lights are an alternative to quitting. 50
The use of numbers to denote light China Canada These numbers are NOT useful as a guide for how harmful these cigarettes are 51
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 52
A little lower means more loving care! Low-harm cigarettes give you more loving care....the worldʼs most advanced low-harm cigarette technology, offering a guarantee of health for your smoking life. A little lower means more loving care! Low-harm cigarettes give you more loving care! Cigarettes contain conflicting elements of pleasure and harm. Zhongnanhai has always focused on research and development of low-harm cigarette technology. Every product fuses the world s most advanced low-harm cigarette technology, offering a guarantee of health for your smoking life. (Advertisement for Zhongnanhai Lights Cigarettes published in the September, 2006 issue of the company s monthly magazine Zhongnanhai World.) 53
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Lighter package colors imply lower harm 56
Descriptors focusing on taste: LACK of harshness 57
Adopt nanometer technology to decrease harmful ingredients. 58
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The Impact of Linguistic Terms, Colors, and Design Elements on Consumers Perceptions David Hammond s experimental studies Create high quality realistic photos of cigarette packs Experimentally vary single elements of labels, brand descriptors, and other elements of the packages Consumers view pairs of packs that are of the same brand, but which differ by one element. They answer questions about important issues in labelling -- Which one do you like would deliver less tar? -- smoother taste -- lower health risk 63
Light >Less Tar, Lower Health Risk 64
Light >Less Tar, Lower Health Risk 65
Chinese tobacco control efforts should move toward... removal of ALL methods of implying that this brand is less harmful Other words besides light/mild Colours that are lighter Claims of technology Plain packaging this may be in the distant future for China, but it would satisfy the goals of reducing the ways in which the industry misleads people to thinking that a brand is somehow safer. 66
There is NO such thing as a safer cigarette 67
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