FCTC Article 11 Guidelines

00__Front cover.pdf 1 3/23/11 12:40 AM

Simplifying the WHO FCTC ARTICLE GUIDELINES Evidence-Based Best Practices 11

CMY

Southeast Asia Tobacco Control Alliance September 2010 00_Authors.pdf 1 6/7/11 1:13 AM

Authors David Hammond, Ph.D. Assistant Professor Department of Health Studies & Gerontology University of Waterloo

Tan Yen Lian, M.A. Knowledge and Information Manager Southeast Asia Tobacco Control Alliance (SEATCA)

Ulysses Dorotheo, MD Southeast Asia Initiative on Tobacco Tax (SITT) Director Southeast Asia Tobacco Control Alliance (SEATCA)

Published by Southeast Asia Tobacco Control Alliance (SEATCA) Thakolsuk Place, Room 2B, 115 Thoddamri Road, Dusit, Bangkok 10300, Thailand Tel: +66 2 668 3650 Fax: +66 2 241 0082 Website: www.seatca.org E-mail: [email protected]

Second Published May 2011, 500 copies

C ISBN 978-616-90022-3-9

Y CM Printed by MY Manus Film Limited Partnership

CY 104/18-20 Soi Krungthepnon 13, Krungthepnon Road, Bangkhen Muang Nonthaburi, Nonthaburi, 11000 Thailand CMY

Supported by International Union Against Tuberculosis and Lung Disease

Copyright text © Southeast Asia Tobacco Control Alliance (SEATCA) Copyright photographs © as indicated separately 01.pdf 1 3/23/11 12:43 AM

Executive Summary

Southeast Asia is a critical region for tobacco control. Approximately 125 million or 30% of all adults in Southeast Asia are current smokers, and tobacco consumption is increasing. Being amongst the largest producers and consumers of tobacco products in the world, Southeast Asia is regarded by the global tobacco industry as a very important market for global expansion. If little is done to reduce tobacco use in the region, already high tobacco-related mortality rates and productivity losses will continue to worsen. Currently 5.4 million people die annually from tobacco use in the world. By 2030, this figure could rise to 8 million deaths per year, 80% of which will be in low and middle-income countries. Urgent action must be taken to curb this growing wave of death and disease.

In 2008, new international guidelines for tobacco packaging and labeling were established under Article 11 of the World Health Organization’s Framework Convention on Tobacco Control (FCTC)-the first global treaty devoted to public health. Tobacco packaging serves as a critical link to consumers, both for the tobacco industry and for governments seeking to convey the health risks of smoking. The brand imagery of the package is the foundation upon which all other marketing is built and plays an even greater role in jurisdictions where traditional forms of advertising, promotion, and sponsorship are restricted.

C This report focuses on health warnings and other packaging regulations in the following M Southeast Asia countries: Brunei, Cambodia, Indonesia, Lao PDR, Malaysia, Philippines, Y Singapore, Thailand, and Vietnam.

CMY

K 02.pdf 1 3/23/11 12:43 AM

Acknowledgement

As part of the Southeast Asia Tobacco Control Alliance (SEATCA)’s effort in advancing the Framework Convention on Tobacco Control (FCTC) in the region, this booklet aims to be a guide to the FCTC Article 11 (Packaging and Labelling of Tobacco Products) Guidelines, drawing insights from evidence-based best practices in developing effective health warning labels and other packaging regulations. It also provides a picture of the current status of the implementation of tobacco health warnings in Brunei, Cambodia, Indonesia, Lao PDR, Malaysia, Philippines, Singapore, Thailand, and Vietnam.

It is hoped that this booklet will strengthen countries’ capacities to implement FCTC Article 11 in order to meet their treaty obligations particularly among ASEAN countries.

CMY

Photo Credits

Dr David Hammond, Assistant Professor, University of Waterloo Ms Tan Yen Lian, Knowledge and Information Manager, SEATCA Brunei Ministry of Health Malaysia Ministry of Health Singapore Health Promotion Board Thailand Ministry of Public Health 03.pdf 1 3/23/11 12:39 AM

4 Section 1 Introduction

5 Section 2 Health Warnings Section 2.1 Background 5 Section 2.2 International Requirements under the WHO FCTC Treaty 7 Section 2.3 Position & Location on Packages 8 Section 2.4 Size 9 Section 2.5 Pictorial Warnings 10 Section 2.6 Colour 12 Section 2.7 Message Content 13 Section 2.8 Language and Literacy Level 15 Section 2.9 Source Attribution 17 Section 2.10 Rotation 18 Section 2.11 International Cooperation 19 Section 2.12 Additional Information on Best Practices in Warning Label Design 19 Table of Contents

20 Section 3 Emissions and Constituent Labelling Section 3.1 Overview 20 C Section 3.2 International Requirements under the M WHO FCTC Treaty 21 Y Section 3.3 Removing Quantitative Information 21

CM Section 3.4 Qualitative Statements 22 Section 3.5 Prohibiting Display of Emission Numbers 23 MY Section 3.6 Other Best Practices in Designing Emision Information 25 CY

CMY

K 26 Section 4 Prohibitions on Misleading Packaging Information Section 4.1 Background 26 Section 4.2 International Requirements under the WHO FCTC Treaty 26 Section 4.3 Misleading Terms 27 Section 4.4 Logos, Colours, and Brand Imagery: Plain Packaging 29 Section 4.5 Expiry date 31

32 Section 5 Legal Measures and Enforcement 35 Section 6 Countering Tobacco Industry Arguments : The Facts 44 Section 7 Health Warnings in the Southeast Asian Region 52 Section 8 Additional References and Sources of Evidence 53 References

61 About SEATCA 04.pdf 1 6/7/11 1:15 AM

1 INTRODUCTION

Southeast Asia is a critical region for tobacco Packaging also serves as a link to other forms control. Approximately 125 million or 30% of of tobacco advertising.6,12 Packs play a all adults in Southeast Asia are current central role in point-of-sale marketing and smokers, and tobacco consumption is help to increase the reach of “below the line” increasing. Being amongst the largest marketing activities, such as concerts, and producers and consumers of tobacco nightclub promotions.6,8,13 The package products in the world, Southeast Asia is assumes even greater importance in regarded by the global tobacco industry as jurisdictions with comprehensive advertising a crucial market for global expansion. If restrictions,11 as highlighted by the following tobacco use remains unchecked, countries quote from a Phillip Morris executive: "Our will face higher tobacco-related mortality and final communication vehicle with our smoker productivity losses. Currently 5.4 million is the pack itself. In the absence of any other people die annually from tobacco use in the marketing messages, our packaging...is the world. Urgent action must be taken to reduce sole communicator of our brand essence. Put and reverse this death toll, of which more another way—when you don’t have anything 14 C than 80% of the world’s tobacco-related else—our packaging is our marketing.”

M deaths will be in low and middle-income 1 Y countries by 2030. International guidelines for tobacco packaging

CM and labelling have been established under

MY Article 11 of the World Health Organization’s Framework Convention on Tobacco Control CY (FCTC)-the first international treaty devoted CMY to public health. The guidelines were adopted K at the Conference of the Parties (COP3) in Tin casing with cigarette pack November 2008.

The Article 11 guidelines cover three primary areas: Tobacco packaging serves as an integral component of tobacco marketing. The pack 1) government-mandated health warnings, provides a direct link between consumers and manufacturers, and is particularly 2) labelling of tobacco constituents and important for consumer products such as emissions, and cigarettes which have a high degree of social visibility.2-10 Unlike many other consumer 3) the removal of misleading information products, cigrette packages are displayed each time the product is used and are often from the package. left in public view between uses.6 As a result, both smokers and non-smokers report high levels of exposure to tobacco packaging.6,11

4 05.pdf 1 3/28/11 2:33 AM

2 HEALTH WARNINGS

2.1 Background

In addition to serving as a marketing vehicle for the tobacco industry, cigarette packages also provide governments with a direct means of communicating with smokers. Warning labels are primarily intended to communicate the health risks of smoking and to fulfill the government’s regulatory responsibility to warn consumers about hazardous products.

Tobacco packages are an excellent medium for providing health information given their reach and frequency of exposure. Package health warnings are also unique among tobacco control initiatives in that they are delivered at the time of smoking and at the point of sale. As a result, health warnings on cigarette packages are among the most prominent sources of health C information for smokers: smokers in countries with comprehensive health warnings are more M likely to report getting information about the risks of smoking from packages than from any Y other source except television.15 Findings from Canada, Thailand, and elsewhere also indicate CM that considerable proportions of non-smokers report awareness and knowledge of package MY health warnings. 11,16, 17

CMY

K At present, cigarette packages in the vast majority of countries carry a health warning.18 However, the position, size, and general strength of these warnings vary considerably across jurisdictions. At least 37 countries and jurisdictions have implemented pictorial health Pictorial health warnings warnings or have passed regulations requiring are found to be a strong deterrent their implementation in the near future (Figure 1). Currently, four out of the 10 ASEAN countries have implemented pictorial warnings; Singapore was among the first countries in the world to implement pictorial health warnings on tobacco packages in 2004 and has since been followed by Thailand (2005), Brunei (2008) and Malaysia (2009).

5 06.pdf 1 3/28/11 2:35 AM

Figure 1. Countries with pictorial health warnings (as of August 2010)

CMY

Note: Numbers indicate the year of implementation, including different years where there have been two or more rounds of picture warnings. Many other countries/jurisdictions are in the process of doing so, or have stated that picture warnings are under consideration.

6 07.pdf 1 6/7/11 1:19 AM

2.2 International Requirements under the World Health Organization FCTC Treaty

All countries that have ratified the FCTC (i.e., “Parties”), are required to implement packaging and labelling measures under FCTC Article.11.19

FCTC Article 11

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 to ensure that:

C ….Each unit packet and package of tobacco products and any M outside packaging and labelling of such products also carry Y health warnings describing the harmful effects of tobacco use, CM and may include other appropriate messages. These warnings MY and messages: (i) shall be approved by the competent national CY

CMY authority; (ii) shall be rotating; (iii) shall be large, clear, visible and

K legible; (iv) should be 50% or more of the principal display areas but shall be no less than 30% of the principal display areas; (v) may be in the form of or include pictures or pictograms.

In addition, Article 11 Guidelines were developed and adopted to provide additional guidance on implementing health warnings (http://apps.who.int/gb/fctc/PDF/cop3/FCTC_COP3_7-en.pdf).20 While Parties are not required to implement the recommendations included in the Guidelines, the Guidelines are based on international best practice and intended to assist countries seeking to develop effective health warnings. These recommendations have been integrated in the following sections.

7 08.pdf 1 3/28/11 12:56 PM

2.3 Position and Location on Packages

Article 11 Guidelines (Paragraphs 8-11) Article 11.1(b)(iii) of the Convention specifies that each Party shall adopt and implement effective measures to ensure that health warnings and messages are large, clear, visible and legible. The location and layout of health warnings and messages on a package should ensure maximum visibility. Research indicates that health warnings and messages are more visible at the top rather than the bottom of the front and back of packages. Parties should require that health warnings and messages be positioned:

on both the front and back (or on all main faces if there are more than two) of each unit packet and package, rather than just one side, to ensure that health warnings and messages are highly visible, recognizing that the frontal display area is the one most visible to the user for most package types; on principal display areas and, in particular, at the top of the principal display areas rather than at the bottom to increase visibility; and in such a way that normal opening of the package does not permanently damage or conceal the text or image of the health warning.

Parties should consider requiring, in addition to the health warnings and messages referred to in paragraph 8, further health warnings and messages on all sides of a package, as well as on package inserts and onserts. Parties should ensure that health warnings and messages are not obstructed by other C required packaging and labelling markings or by commercial onserts and inserts. Parties M should also ensure, when establishing the size and position of other markings, such as tax

Y stamps, and markings as per the requirements of Article 15 of the Convention, that such

CM markings do not obstruct any part of the health warnings and messages.

MY Parties should consider introducing other innovative measures regarding location, including,

CY but not limited to, requiring health warnings and messages to be printed on the filter overwrap portion of cigarettes and/or on other related materials, such as packages of cigarette tubes, CMY filters and papers as well as other instruments, such as those used for water pipe smoking. K

Evidence

Few research studies have explicitly examined whether warnings placed on the “top” of packs are more effective; however, logic and anecdotal evidence suggests this is the case. This is particularly true at the point of sale, where shelving units often obscure the bottom of the package and, any warnings that appear on the bottom of packages make it less noticeable. Warnings that appear only on the back side of packages, such as in Brazil, are also obscured at the point of sale and less visible to the public as a result. There is substantial evidence that health warnings that only appear on the side of packs are hardly noticeable, including evidence from the United States, where health warnings were implemented on the side of packs in 1984.15 Pre-testing study on the label position of pictorial health warnings in Singapore showed that images placed on the top of cigarette packs were found to be most attention catching.21 The majority of countries that have implemented pictorial warnings require warnings to appear on the front and back of packages. In Singapore, Thailand, Brunei and Malaysia require pictorial health warnings to be placed on the top front and back panels of the pack. Cambodia has recently moved health warnings from the side panel to the front and back of the pack.

8 09.pdf 1 6/7/11 1:20 AM

Current International Best Practice

The majority, but not all, of the countries that require pictorial warnings require that they be positioned at the top of packages, as recommended in the Guidelines. Countries such as Uruguay require large warnings to be displayed at the top of the front and back of packages. ASEAN countries, including Australia: Additional Singapore, Thailand, Malaysia and Brunei also information on require pictorial warnings to appear at the top of the quitting and more front and back of packages. Several countries have detailed health information at the used the front and back of the pack to communicate back of the pack different types of information. For example, Australia uses the back of the pack to include additional information on quitting and more detailed health information, whereas countries such as Canada use different languages on each side of packages.

Several countries, including Canada, Australia, Brunei, Singapore and Malaysia also have legislation that prohibits any packaging elements from obstructing or obscuring health C warnings. To date no countries have adopted innovative measures such as requiring health M warnings on cigarettes themselves, or directly on the overlap. Recently Australia has Y progressed to implement plain or generic packaging which will enhance the prominence and CM effectiveness of health warnings22 (see also Section 4.4).

CMY K 2.4 Size

Article 11 Guidelines (Paragraphs12-13)

Article 11.1(b)(iv) of the Convention specifies that health warnings and messages on tobacco product packaging and labelling should be 50% or more, but shall be no less than 30%, of the principal display areas. Given the evidence that the effectiveness of health warnings and messages increases with their size, Parties should consider using health warnings and messages that cover more than 50% of the principal display areas and aim to cover as much of the principal display areas as possible. The text of health warnings and messages should be in bold print in an easily legible font size and in a specified style and colour(s) that enhance overall visibility and legibility.

If a border is required, Parties should consider excluding the space dedicated to framing health warnings and messages from the size of the health warning or message itself when calculating the percentage of display area occupied by them; that is, the space dedicated to the frame should be added to the total percentage of space occupied by the health warnings and messages, and not included within it.

9 10.pdf 1 3/29/11 12:55 PM

Evidence

Smokers are more likely to recall larger warnings, and have been found to equate the size of the warning with the magnitude of the risk. 23-29 A Phillip Morris document also highlights the importance of positioning on the front of packages: “Government required warnings placed on the largest packaging panel, often called the front and/or back, are the biggest marketing threat to all of us in Asia...”14 Features that distinguish the warning messages from the package design have also been found to increase the salience and recall of warnings.30 Messages with contrasting colours, such as black lettering on a white background are the easiest to read, whereas the legibility of silver or gold text is comparatively poor.26,31

Current International Best Practice

Uruguay currently has the largest health warnings in the world. Their pictorial warnings cover 80% of the front and back of packages. In Mauritius, warnings cover 60% of front, and 70% of back, whereas countries such as Australia have implemented warnings on 90% of the back and 30% of the front of packages. In 1992 Thailand issued regulation on textual health warnings. Since there was no evidence to determine whether white letter on black background or black letter on white background was more effective, tobacco companies were given a choice. No company chose black letter on white background. Their action indicated that white letter on black background is more effective. Subsequent change in regulation mandated tobacco companies to use white letter on black background only.32 C

Y CM 2.5 Pictorial Warnings MY

CMY Article 11 Guidelines (Paragraphs 14-17) K Article 11.1(b)(v) of the Convention specifies that health warnings and messages on tobacco product packaging and labelling may be in the form of or include pictures or pictograms. Evidence shows that health warnings and messages that contain both pictures and text are far more effective than those that are text-only. They also have the added benefit of potentially reaching people with low levels of literacy and those who cannot read the language(s) in which the text of the health warning or message is written. Parties should mandate culturally appropriate pictures or pictograms, in full colour, in their packaging and labelling requirements. Parties should consider the use of pictorial health warnings on both principal display areas (or on all main faces if there are more than two) of the tobacco product’s packaging. Evidence shows that, when compared with text-only health warnings and messages, those with pictures: are more likely to be noticed; provoke more thought about the health are rated more effective by tobacco users; risks of tobacco use and about cessation; are more likely to remain salient over time; increase motivation and intention to quit; and better communicate the health risks of tobacco use; are associated with more attempts to quit. Pictorial health warnings and messages may also disrupt the impact of brand imagery on packaging and decrease the overall attractiveness of the package. When creating pictures for use on tobacco product packaging, Parties should obtain, where possible, ownership or full copyright of images, instead of allowing graphic designers or other sources to retain copyright. This provides maximum flexibility to use the images for other tobacco control interventions, including mass media campaigns and on the Internet. It may also enable Parties to grant licenses to other jurisdictions to use the images.

10 Evidence

A wide variety of studies have demonstrated the superiority of using pictures and imagery in health communications, rather than text-only messages.27,33-37 Health warnings with pictures are significantly more likely to draw attention and result in greater processing, and memory of the accompanying text. Picture warnings also encourage individuals to imagine health consequences and are more likely to be accessed when an individual is making relevant judgments and decisions. Pictures such as this effectively Experimental research on cigarette pack warnings has also convey health messages even found that picture-based warnings are more likely to be rated to the illiterate as effective versus text-only warnings, both as a deterrent for new smokers and a means to increase cessation among current smokers.38,39 Opinion surveys in most ASEAN countries also showed that majority of smokers and non-smokers perceived that a combination of textual and pictorial health warnings is more effective in educating public about health risk of smoking 40-44 C and encourage quit attempt among smokers. Extensive

M focus group testing and market-research commissioned by

Y government health agencies also underscores the importance 45-51 CM of using pictures in package health warnings.

CY Since 2000, when the first pictorial warnings were introduced

CMY in Canada, a series of population-based surveys have

K compared the effectiveness of text and pictorial warnings. These findings are consistent with both the experimental and government commissioned research: graphic warnings are more likely to be noticed and read by smokers, and are Pictorial associated with stronger beliefs about the health risks of health warnings are smoking, as well as increased motivation to quit more effective 38-39,45-49,52-57 than textual smoking. Picture warnings are especially effective ones among youth57, and among populations with lower literacy rates.58-61 In Thailand, a cohort study of smokers found that increasing the size and adding graphic images to warning labels greatly increases their effectiveness. A comparison of findings from Wave 1 (2005) and Wave 2 (2006) of the cohort study (after the implementation of 50% pictorial health warning on cigarette pack enhancement from 30% text-only in 2005), revealed that Thai smokers stating that the labels made them think about the health risks “a lot” increased from 34% to 53%, and those stating that the labels made them “a lot” more likely to quit increased from 31% to 44%.62

11 12.pdf 1 6/7/11 1:22 AM

“Graphic” Fear-Arousing Picture Warnings Are Credible Messages Are Most Effective and Are Supported by the Public Health warnings that arouse strong emotional reactions are most likely to be effective.54 Although tobacco companies have suggested Smokers and non-smokers, as well as youth that pictorial warnings “harass” smokers, and adults consistently identify images that research suggests that, overall, smokers depict graphic health effects as being the welcome more health information on their most memorable and the images that are packages, including information that presents most likely to prevent smoking or motivate the health consequences of smoking in a quitting. A study of 1,300 smokers and vivid, arousing manner. Several studies also non-smokers in Singapore found that images report high levels of public support for graphic of smoking causes lung cancer and stroke pictorial warnings, including among a majority were rated to provide the highest impact in of smokers.54,63,64 encouraging smokers to quit smoking or discouraging non-smokers from taking up smoking.21 However, there are a number of Current International different themes that may evoke strong Best Practice emotional reactions that do not involve pictures of diseased organs. Recommendations for More than 30 countries have implemented C content are available in the Tobacco Labelling pictorial warnings to date. Most of these M Toolkit at www.tobaccolabels.ca. countries require pictorials to appear on the Y front and back of packs, as per CM recommendations under the Guidelines. A list MY of countries that have implemented pictorial CY warnings appears in section 2.1; additional CMY information on pictorial warnings in the ASEAN K region is available in section 7.0 of this document.

2.6 Colour

Article 11 Guidelines (Paragraph 18)

The use of colour, as opposed to black and white, affects the overall noticeability of pictorial elements of health warnings and messages. Therefore, Parties should require full colour (four colour printing), rather than black and white, for pictorial elements of health warnings and messages. Parties should select contrasting colours for the background of the text in order to enhance noticeability and maximize the legibility of text-based elements of health warnings and messages.

12 Evidence Current International Best Practice

Research on pictorial warnings provides At present, all countries that have strong evidence on the impact of using colour implemented pictorial warnings have done so in health warnings. For example, in a study using colour. The selection of background of Canadian smokers, participants felt that the colours and contrasting colours for text varies new larger health warning messages, widely. Countries such as Thailand and featuring colour photographs, were a definite Australia have used white text on black improvement over black and white text backgrounds for the main portion of the health warnings.45 Messages with contrasting warning, with Australia also using white text colours, such as black lettering on a white on a red background for the main “marker” background are the easiest to read, whereas word (e.g., “Warning”). the legibility of silver or gold text messages is comparatively poor.54, 65

2.7 Message Content C

Y Article 11 Guidelines (Paragraphs 23-27)

MY Using a range of health warnings and messages increases the likelihood of impact, as different health warnings and messages resonate with different people. Health warnings and messages should address CY different issues related to tobacco use, in addition to harmful health effects and the impact of exposure CMY to tobacco smoke, such as: advice on cessation; the addictive nature of tobacco; adverse economic K and social outcomes (for example, annual cost of purchasing tobacco products); and the impact of tobacco use on significant others (premature illness of one’s father due to smoking, for example, or death of a loved one due to exposure to tobacco smoke).

Parties should also consider innovative content for other messages, such as adverse environmental outcomes and tobacco industry practices.

It is important to convey health warnings and messages in an effective manner; the tone should be authoritative and informative but non-judgmental. Health warnings and messages should also be presented in simple, clear and concise language that is culturally appropriate. Health warnings and messages can be presented in various formats, such as testimonials, or positive and supportive information.

The provision of advice on cessation and specific sources for cessation help on tobacco packaging, such as a website address or a toll-free telephone “quit line” number, can be important in helping tobacco users to change their behaviour. Parties should be aware that an increased demand for cessation-related services might require additional resources.

13 Evidence

Evidence suggests that health warnings and messages are likely to be more effective if they elicit unfavourable emotional associations with tobacco use and when the information is personalised to make the health warnings and messages more believable and personally relevant. The effectiveness of graphic fear-inducing images is supported by surveys and focus groups with smokers. For example, an extensive public consultation was conducted by the UK Department of Health that received more than 20,000 responses. The highest rated warnings were generally those that included the “hardest hitting” messages and images, including graphic pictures of the health effects of smoking.66 Similarly in Thailand, a majority of 2,183 respondents from a public opinion poll in 2003 rated the images of smoking cause lung, mouth and throat cancers as the highest and most suitable picture for health warnings.32 In Malaysia, a graphic health warning efficacy testing found that the use of vivid photos with a high degree of severity and fear appeal have the potential to evoke strong emotion and stimulate thinking.67 Research conducted on behalf of the Australian, New Zealand, and Canadian governments yielded similar results. The following summary from Canadian focus groups is typical of other studies in this area: “Participants in all groups consistently expected or wanted to be shocked by health warning messages (HWMs), or emotionally affected in some way. Even if the feelings generated were unpleasant ones, such as disgust, fear, sadness or worry, the emotional impact of a warning C appeared to predict its ability to inform and/or motivate thoughts of quitting. HWMs which worked M on emotions rather than on knowledge or beliefs were often acknowledged as effective and Y noticeable, and actually motivated thinking. When a strong emotion generated by a HWM was CM supported by factual information that was the best combination possible.”49

CY Health warnings and messages that generate negative emotions such

CMY as fear can be effective, particularly when combined with information

K designed to increase motivation and confidence in tobacco users in their ability to quit. In fact, research in the field of health communication indicates that messages with emotionally arousing content are more likely to be noticed and processed by smokers. The most consistent finding from this literature is that fear appeals are effective when paired with strong efficacy messages for a specific outcome (i.e. quitting smoking). A recent meta-analysis of the literature on public health communications concluded that strong fear appeals and high-efficacy messages produce the greatest behavior change, Quitline number on and found no evidence of any adverse or ‘boomerang’ effects for Singapore strong fear appeals.65 Pictorial warnings in Canada, Australia, cigarette packs Singapore, Brazil, and other countries are entirely consistent with this literature: in addition to information on health risks, they include messages designed to increase self-efficacy for quitting. These messages include both general messages of support, as well as concrete information on ways to quit smoking and specific sources of help, including website addresses and toll-free “quitline” numbers.

14 15.pdf 1 6/7/11 1:24 AM

Current International Best Practice

Countries have taken different approaches to message content. For example, in 2009, Brazil implemented the most shocking, fear-arousing images to be implemented in any Inserts provide country. A number of countries in the ASEAN region have also additional health implemented strong pictorial warnings, beginning with information Singapore, as well as Thailand, Brunei, Malaysia and others. Research to date suggests that strong warnings such as these are likely to be most effective, particularly when accompanied by a telephone quitline and other forms of cessation support on the package. While Singapore was among the first countries in the world to print a toll-free telephone “quitline” on packages, Australian warnings currently include the greatest amount of quit support integrated with the health warnings. Canada has also set precedents for including cessation information and quit tips on the “inside” of packages, using an insert (see example at right).

C M 2.8 Language and Literacy Level Y

MY Article 11 Guidelines (Paragraphs 28-29)

CY Article 11.3 of the Convention specifies that each Party shall require that the warnings and CMY other textual information specified in Article 11.1(b) and Article 11.2 appear on each unit K packet and package of tobacco products, as well as on any outside packaging and labelling of such products, in the Party’s principal language or languages.

In jurisdictions where there is more than one principal language, health warnings and messages can be displayed on each principal display area in more than one language, or, alternatively, a different language can be used for different principal display areas. Where appropriate, different languages or language combinations could also be used in different regions of a jurisdiction.

Evidence

The message content of text-based warnings must target an appropriate literacy level.58 The US warnings implemented in 1984 until 2011, for example, required a college reading level and may have been inappropriate for youth and Americans with poor reading abilities.59 This is particularly important considering that, in many countries, smokers report lower levels of education than the general public. Picture-based warnings may be particularly important in communicating health information to populations with lower literacy rates.49,60 Preliminary evidence suggests that countries with pictorial warnings demonstrate fewer disparities in health knowledge across educational levels.61

15 Current International Best Practice

Health warnings in most countries include text with appropriate reading levels. Health warnings in countries with multiple languages require special consideration. In Canada, which has two official languages, the same warning appears in French on one side of the package and in English on the other side. Other jurisdictions have included more than one language in the same warning. For example, the Belgian warnings, shown at right, display the text in Dutch, French, and German. Because this requires additional space, the size of the Belgian warnings is larger than the minimum European Union standard. Another option is to create separate warnings in each language and then stipulate that the warnings from each language be randomly printed on different packages. In all cases, the use of pictures Belgian’s pictorial health warnings in accompanying the text will be extremely important, given that three languages including Dutch, pictures are universal across languages. French and German

CMY

Malaysia’s pictorial health warnings in two languages, Malay (front) and English (back) Brunei’s pictorial health warnings in two panels languages, Malay (front) and English (back) panels

16 2.9 Source Attribution

Article 11 Guidelines (Paragraphs 30-31)

An attribution statement gives an identified source for the health warnings and messages on tobacco product packaging. There are, however, mixed views about whether they should form part of health warnings and messages. Some jurisdictions have provided a source attribution statement in order to increase the credibility of the health warnings and messages, while others have decided not the health warnings and messages, while others have decided not to include a source attribution out of concern that it might detract from the impact of the warning. Where a source attribution statement is required, it is often located at the end of the health warning, in a smaller font size than the rest of the warning. Ultimately, Party-specific circumstances, such as beliefs and attitudes among target population subgroups, will determine whether the use of source attribution is likely to increase credibility or reduce impact.

If required, a source attribution statement should specify a credible expert source, such as the national health authority. The statement should be small enough not to detract from the overall noticeability and impact of the message, while being large enough to be legible.

C Evidence Current International Best

M Practice

Y Research indicates that smokers report pictorial warnings Warnings in countries such as Canada, Australia, Brazil, CM to be a credible source of information, particularly when and Venezuela include text attributing the health warning MY attributed to a well-respected Department of Health or a to the government or some other source. However, this CY well respected non-governmental authority, such as a 48,68,69 is not the case in many other countries, including CMY cancer society. In countries where the government members of the European Union, and in Southeast Asia K health ministry is well regarded and has high credibility, countries such as Malaysia and others. Often, the name attribution to a government source may increase the of the health ministry is included in small letters at the end believability of the information; however, if the government of the warning. In other cases, the attribution is included is generally disliked or mistrusted, attribution to as part of the preamble to the warning, such as: “The government sources may result in rejection of the health Department of Health and Welfare advises...” Overall, warning. Attributions also require valuable space that however, there is no clear consensus as to whether could be devoted to other information. It should also be attributions increase or decrease the credibility of noted that the tobacco industry has previously lobbied for warnings. If attributions are included as part of the government attribution, perhaps to distance itself from the warning, the attribution should be made to a health health messages. authority rather than the government in general. The attribution should also be relatively small to minimise the space it occupies and should appear at the bottom or end of the text message, rather than at the beginning.

17 2.10 Rotation

Article 11 Guidelines (Paragraphs 19-22)

Article 11.1(b)(ii) of the Convention specifies that health warnings and messages shall be rotating. Rotation can be implemented by having multiple health warnings and messages appearing concurrently or by setting a date after which the health warning and message content will change. Parties should consider using both types of rotation.

The novelty effect of new health warnings and messages is important, as evidence suggests that the impact of health warnings and messages that are repeated tends to decrease over time, whereas changes in health warnings and messages are associated with increased effectiveness. Rotation of health warnings and messages and changes in their layout and design are important to maintain saliency and enhance impact.

Parties should specify the number of health warnings and messages that are to appear concurrently. Parties should also require that health warnings and messages in a specified series be printed so that each appears on an equal number of retail packages, not just for each brand family but also for each brand within the brand family, for each package size and type.

Parties should consider establishing two or more sets of health warnings and messages, specified from the outset, to alternate after a specified period, such as every 12–36 months. During transition periods, when an old set of health warnings and messages is being replaced by a new set, Parties should provide for a phase-in period for rotation between sets of health warnings and messages, during which time both sets may be used

C concurrently.

CM Evidence Current International Best MY

CY Practice Evidence suggests that the impact of health warnings CMY Several countries have regularly updated their health and messages that are repeated tends to decrease over K warnings. Uruguay has rotated sets of warnings four time, whereas changes in health warnings and times in the period between 2006 and 2010, while Brazil messages are associated with increased effectiveness. has implemented three sets of warnings since 2002. In It is widely accepted that the salience of advertising and Southeast Asia, Thailand has implemented three sets of health communications is typically greatest upon initial health warnings between 2005 and 2010, and Singapore exposure.70,71 For example, a recent study found that has implemented two. In most cases, new sets of health new text-based warnings introduced in the United King- warnings have been achieved through new regulatory dom in 2003 were considerably more likely to be noticed measures. However, countries such as Australia, Mexico than Australian text-based warnings which were only and Brunei have implemented a single regulation which slightly smaller, but had been in place for more than eight stipulates the rotation period for different sets of health years at the time of the survey.72 The frequency with warnings in the future. For example, Malaysia has an which smokers pay attention to warnings has been administrative order that requires a two-year period of shown to lessen over time as smokers become rotation, while in Mexico, a set of eight health warnings desensitized to the warnings.73,74 As a result, health is to be implemented for the year beginning September warnings must be regularly updated to maintain their 2010 with a second set scheduled for the following year. maximum impact over time. Moreover, the Mexican regulation requires two health warnings to be released every three months during these periods.

18 2.11 International Cooperation

Article 11 Guidelines (Paragraphs 72-74)

International cooperation is essential for progress in such an important, constantly changing area as tobacco control. Several articles of the Convention provide for the exchange of knowledge and experiences to promote progress in implementation, with particular focus on the needs of developing country Parties and Parties with economies in transition. Cooperation among Parties to promote the transfer of technical, scientific and legal expertise and technology, as required by Article 22, would strengthen the implementation of Article 11 of the Convention globally. One example of such cooperation would be the provision of licenses quickly, easily and without cost from Parties to other jurisdictions seeking to use their pictorial health warnings. International cooperation would also help to ensure that consistent and accurate information relating to tobacco products is provided globally.

Parties should endeavour to share legal and other expertise in countering tobacco industry arguments against packaging and labelling measures.

Parties should consider reviewing the reports of other Parties, pursuant to Article 21 of the Convention, to enhance their knowledge of international experience with respect to packaging and labeling.

In strengthening the implementation of Article 11 in the ASEAN region, the Southeast Asia Tobacco Control Alliance (SEATCA) under its Resource Center initiative has established an C image bank of copyright-free pictorial health warnings (PHWs) from Brunei, Malaysia, Singapore M and Thailand in accordance with the work plan agreed by the ASEAN Focal Points on Tobacco Y Control (AFPTC). AFPTC was set up under the purview of the ASEAN Health Ministers to CM accelerate the implementation of the FCTC within each country and the region.

CY The establishment of the SEATCA Image Bank marks one of the first ASEAN regional

CMY collaboration initiatives to strengthen partnership in advancing implementation of Article 11 of

K the FCTC. The image bank can be accessed through the SEATCA website (www.seatca.org). SEATCA will facilitate application for copyright-free pictorial health warnings from Brunei, Singapore and Thailand and other ASEAN countries as well as provide technical assistance to countries regarding issues pertaining to development and implementation of pictorial health warnings.

2.12 Pre-market Testing, Evaluation and Additional Information on Best Practices in Warning Label Design

Recommendations for premarket testing, evaluation and additional information on best practices in designing health warnings are available at: http://www.tobaccolabels.ca/toolkit

19 EMISSIONS AND 3 CONSTITUENT LABELLING

3.1 Overview

Disclosure of constituents and emissions has presented a unique challenge to government regulators. Cigarette smoke contains approximately 4,000 chemicals, including over 60 carcinogens and toxins such as polonium-210, benzene, and arsenic.75 Although there is general agreement that cigarette packages should include some information on the toxic and addictive properties of tobacco products, regulators continue to struggle with how to communicate this information in a feasible and meaningful way to consumers.

At present, national authorities have taken different approaches to labelling constituents and emissions. The traditional regulatory practice in many jurisdictions has been to require manufacturers

C to print levels for three emissions in the mainstream smoke: tar,

M nicotine, and carbon monoxide (CO). These numbers are typically

Y printed on the side of packages. In fact, communicating emissions

CM numbers to consumers was originally an industry practice.

MY Tobacco manufacturers have communicated tar and nicotine

CY numbers directly to smokers ever since the health risks of 76 CMY smoking became publicly known. These early forms of “product chemical emission K disclosure” were motivated less by consumer protection than by levels can mislead a marketing strategy intended to capitalize upon widespread smokers to believe that one product is misperceptions of “lower tar” products. Despite early objections safer than another by regulatory authorities such as the U.S. Federal Trade Commission, this industry practice has become a common regulatory practice throughout the world.77

The underlying premise for communicating tar and nicotine numbers directly to consumers - that “low tar” cigarettes are less harmful - has been rejected. Not only has the epidemiological data failed to detect differences in risk, but the serious limitations of emission testing methods have also become Emission numbers do not offer apparent.78-80 Scientific consensus is that tar, nicotine, meaningful information and carbon monoxide emission numbers do not offer smokers meaningful information on the amount of tar and nicotine they will receive from a cigarette, or on the relative amounts of tar and nicotine exposure they are likely to receive from smoking different brands of cigarettes.

20 21.pdf 1 6/7/11 1:28 AM

3.2 International Requirements under the World Health Organization FCTC Treaty

FCTC Article 11.2 Each unit packet and package of tobacco products and any outside packaging and labeling of such products shall, in addition to the warnings specified in paragraph 1(b) of this Article, contain information on relevant constituents and emissions of tobacco products as defined by national authorities.

3.3 Removing Quantitative Information

Article 11 Guidelines (Paragraph 34)

M Parties should not require quantitative or qualitative statements on tobacco product

Y packaging and labelling about tobacco constituents and emissions that might imply that

CM one brand is less harmful than another, such as the tar, nicotine and carbon monoxide

MY figures, or statements such as “These cigarettes contain reduced levels of nitrosamines.”

CMY

Evidence

Tar, nicotine, and carbon monoxide emission numbers are misleading. They represent neither the amount of chemicals present in the cigarette (i.e. tobacco “constituents”), nor the amounts actually ingested by human smokers. This is because the emission numbers are determined by a machine that “smokes” cigarettes according to a fixed puffing regime. This machine method does not predict the amount of smoke inhaled by individual consumers or account for design elements such as “filter ventilation” - tiny holes poked in the filter that yield low emission levels under machine smoking, but much higher levels under human smoking.78 As a result, there is no association between the machine-generated numbers printed on packages and the health risk of different Filter ventilation are tiny holes brands. In short, the underlying premise for communicating tar burned using laser and nicotine numbers directly to consumers - that “low tar” in the filter paper of each cigarette cigarettes are less harmful - has since been rejected. butt

21 Research has repeatedly shown that although many smokers are not able to recall the specific tar level of their brand, a substantial proportion nevertheless equate lower numbers with a reduction in exposure and risk, and many use these numbers to guide their choice of brands.74,81-85 Recent findings suggest that smokers even in the most affluent and educated countries continue to hold false beliefs about emission numbers. For example, 75% of smokers from Australia, Canada, the U.S., and the UK recently reported that the tar numbers on packs are related to exposure.86 Among smokers in the same study who believe that some brands are less harmful than others, 81% believe that the tar and nicotine levels indicate the brands that are less harmful.86 When shown emission labels on two cigarette brands from the European Union, 92% of smokers recently reported that the 4 mg product would deliver less tar than the 10 mg product, and 90% reported that they would buy the 4mg product if they were trying to reduce the risks to their health.56 These findings are consistent with the ways in which smokers have been shown to perceive emission numbers when conveyed through advertising.76

Current International Best Practice

A number of countries have removed regulations requiring manufacturers to print tar and nicotine numbers on packages, including Venezuela, Australia, Malaysia, Thailand, Brazil and others. Countries such as Canada and the European Union have indicated their intention to do the same.

C M 3.4 Qualitative Statements Y

CM MY Article 11 Guidelines (Paragraph 33) CY

CMY In implementing this obligation, Parties should require that relevant qualitative statements

K be displayed on each unit packet or package about the emissions of the tobacco product. Examples of such statements include “smoke from these cigarettes contains benzene, a known cancer-causing substance” and “smoking exposes you to more than 60 cancer-causing chemicals”. Parties should also require that this information be shown on parts of the principal display areas or on an alternative display area (such as the side of packaging) not occupied by health warnings and messages.

Evidence

Preliminary research suggests that this information is more meaningful to consumers and less likely to result Canada in misperceptions about the relative risk of different cigarette brands.87 However, there is evidence that the general descriptive messages implemented to date could be improved further. There is extensive evidence that using the internationally recognized Additional useful information for smokers symbol for toxicity - the skull - increases the salience can be added on the side of the pack and comprehension of toxic chemical warning messages, particularly among children and diverse populations, including individuals with low literacy and education rates.88-93

22 Current International Best Practice

A growing number of countries have removed emission numbers from packages and replaced them with descriptive information about toxic constituents and their effects on health. Canada and Thailand were among the first countries to require qualitative statements on packages, in accordance with recommendations from the World Health Organization, and recently followed by Malaysia. In addition, research commissioned by Health Canada found that messages on specific toxic constituents with an explanation of their health effect were rated as most effective.94

Malaysia

This product contains more than 4,000 chemicals including tar, nicotine and carbon monoxide that are dangerous to health

CY CMY 3.5 Prohibiting Display K of Emission Numbers

Article 11 Guidelines (Paragraph 44)

Parties should prohibit the display of figures for emission yields, such as tar, nicotine and carbon monoxide, on packaging and labelling, including when used as part of a brand name or trademark. Tar, nicotine and other smoke emission yields derived from smoking-machine testing do not provide valid estimates of human exposure. In addition, there is no conclusive epidemiological or scientific evidence that cigarettes with lower machine-generated smoke yields are less harmful than cigarettes with higher smoke emission yields. The marketing of cigarettes with stated tar and nicotine yields has resulted in the mistaken belief that these cigarettes are less harmful.

23 Evidence

Numbers incorporated into the name of brands represent another class of descriptors to distinguish between different varieties (see example below). These numbers typically correspond to the machine levels of tar emissions.76 There is extensive research showing that consumers perceive lower tar products as “healthier” than regular or higher tar products.76 When shown packages with different numbers in the brand name, as many as 80% of Canadian adult smokers recently reported that the brand with the lower number would deliver less tar and may lower risk.56

M Numbers to denote tar levels are

Y misleading

CMY A recent study conducted in the United States found that almost 90% of participants reported K that a brand with the number “10” on the packages would have higher risk than an otherwise identical brand with the number “6” in the name.95 Overall, the evidence base for prohibiting numbers is the same as in section 3.3: consumers are misled by these numbers regardless of whether they are provided by regulators as part of emission information or by the industry when printed voluntarily on packages.

Current International Best Practice

To date, no country has prohibited tar numbers from appearing on packages, although a number of countries have removed requirements to display tar numbers, as discussed in Section 3.3.

24 3.6 Other Best Practices in Designing Emission Information

Additional information on designing effective emission and constituent messages is available

at: http://www.tobaccolabels.ca/toolkit. The Thailand following provides a brief summary of key points not addressed in the Guidelines for Article 11 Toxic substance in cigarette smoke : Hydrogen cyanide and Carbon Size & Position monoxide

Emission and constituent messages are typically located on one side of the package. Carcinogen in cigarette smoke : Many jurisdictions have used the entire side, Formaldehyde, up to the point where the package separates Tar, Nitrosamine for “flip-top” packages, to avoid cutting off the text information.

C Contrasting Colours Content of Messages

Y As with health warnings, it is important to There are two main approaches to designing

CM ensure high contrast between the wording and effective emission and constituent messages.

MY the background. White letters on black The first is to include a general statement

CY background or black letters on white about the range of toxic or dangerous

CMY background are the most effective substances. For example, Australian

K combinations. The font size should be messages mention “more than 40 harmful sufficiently large to be legible. chemicals”, while the Brazilian messages mention “4,700 toxic substances.” Focus group testing suggests that this may be an effective Use of Symbols and way to communicate the magnitude of toxic Pictures chemicals in tobacco smoke. These messages The most consistent finding from both can be improved by adding a second sentence quantitative and qualitative research that refers to specific health effects. The conducted among tens of thousands of second approach is to identify specific smokers throughout the world is that pictures chemicals in constituents or emissions. enhance the effectiveness of health warnings. Previous research suggests that the most The same principles that have been adopted common recommendation for improving the in designing the primary health warning side messages was explaining the harmful messages should be applied to the toxic and effects of the chemicals found in cigarettes. constituent message on the side of packages: use pictures to attract attention and improve risk comprehension.

25 PROHIBITIONS ON MISLEADING PACKAGING 4 INFORMATION

4.1 Background 4.2 International Requirements Tobacco companies have made extensive use of cigarette packages to reassure consumers about under the World the potential risks of their products.76,96 A central feature of this strategy has been to use misleading Health brand descriptors-words and numbers incorporated in the name of a brand. Words such as “light” and Organization “mild” are ostensibly used to denote flavor and taste; however, “light” and “mild” brands have also FCTC Treaty been promoted in advertisements as “healthier” 7,76,97 C products. “Light” and “mild” descriptors are also

M applied to brands with higher levels of filter Y ventilation-small holes in cigarette filters. Not only FCTC Article 11.1(a) CM does filter ventilation dilute cigarette smoke to MY produce deceptively low tar and nicotine numbers Each Party shall, within a period of CY under machine testing, but it also produces “lighter” three years after entry into force of this CMY tasting smoke, which reinforces the misleading Convention for that Party, adopt and K descriptors on packages. As a result, considerable implement, in accordance with its proportions of adult smokers believe that “light”, national law, effective measures to “mild”, and “low tar” cigarette brands have lower ensure that: health risk and are less addictive than “regular” or ….tobacco product packaging and “full flavour” brands.76,98-103 Indeed, many health- labelling do not promote a tobacco concerned smokers report switching to these product by any means that are false, brands as an alternative to quitting.78,101 “Light” and “mild” descriptors may also promote smoking misleading, deceptive or likely to create initiation among youth: one study found that U.S. an erroneous impression about its youth believe “light” and “mild” have lower health characteristics, health effects, hazards risk and lower levels of addiction than “regular” or emissions, including any term, brand varieties, similar to adults.104 Overall, the descriptor, trademark, figurative or any synergistic, but subtle effect of brand descriptors, other sign that directly or indirectly lower emission numbers, and the “lighter” tasting creates the false impression that a smoke have undermined perceptions of risk among particular tobacco product is less smokers, leading many to delay or put off quitting harmful than other tobacco products. altogether. These may include terms such as “low tar”, “light”, “ultra-light”, or “mild.”

26 27.pdf 1 6/7/11 6:59 AM

4.3 Misleading Terms

Article 11 Guidelines Evidence

(Paragraph 43) Research conducted in Canada, the UK, Article 11.1(a) of the Convention and Australia suggests that prohibiting “light” specifies that Parties shall adopt and and “mild” terms may be insufficient to implement, in accordance with their significantly reduce false beliefs about the 34 national law, effective measures to risks of different cigarette brands. Indeed, ensure that tobacco product packaging recent evidence suggests that significant and labelling do not promote a tobacco proportions of adult smokers and youth in product by any means that are false, countries such as the UK continue to report misleading, deceptive or likely to create false beliefs about the relative risk of leading 105 an erroneous impression about the cigarette brands. One potential explanation product’s characteristics, health effects, for these findings is the wide range of other hazards or emissions, including any descriptors that remain in use, including words term, descriptor, trademark or figurative such as “smooth”, colour descriptors such as or other sign that directly or indirectly “silver” and “blue”, as well as “tar” numbers creates the false impression that a that are incorporated into brand names or 106 particular tobacco product is less harmful printed on the sides of packs. than others. These may include terms such as “low tar”, “light”, “ultra-light” or The names of colours are among most “mild”, this list being indicative but not common replacement descriptors following 106 C exhaustive. In implementing the prohibitions on “light” and “mild” descriptors. M obligations pursuant to Article 11.1(a), For example, in many countries that have Y Parties are not limited to prohibiting the prohibited the term “light”, Marlboro Light has

CM terms specified but should also prohibit been relabeled as Marlboro Gold. Three recent studies have examined consumer MY terms such as “extra”, “ultra” and similar perceptions of colour descriptors in Canada, CY terms in any language that might mislead the UK and the United States. The findings CMY consumers. from these studies indicate that consumer K perceive the colour descriptors in the same way as the “light” and “mild” descriptors they replaced. For example, more than three quarters of US adults surveyed indicated that a brand labeled as “silver” would have lower levels of tar and less health risk than a “full flavour” brand.95

Studies conducted in the UK and Canada after the removal of “light” and “mild” descriptors suggest that replacement words such as “smooth” have the same misleading effect as light and mild: as many as half of Descriptor such as ‘Mild’ gives a adults and youth in these studies reported false impression that it is less that a brand labelled “smooth” would have hazardous to health lower risk than its “regular” counterpart.56,105 Research has also shown that youth may perceive brands that are labeled as “organic” or “natural” as less harmful.107

27 28.pdf 1 6/7/11 7:03 AM

Smoking does not make a person slim as the brand name implies

Female-oriented brand descriptors such as “slims” target beliefs about smoking and weight control-an important predictor of smoking behaviour among young women.108-110 Women and adolescent girls hold a common belief that smoking is an effective weight control strategy. Not only are females more likely to endorse this belief than males, they are also more likely to report using cigarettes as a weight loss method.111

Research suggests that smoking initiation is higher among girls who highly value thinness, engage in dieting behaviours, express concern over body weight, or have negative views of their bodies.112,113 Although there is an established link between smoking and weight gain, beliefs about the association between smoking and weight tend to be exaggerated among young women.114 Recent research conducted among young women in Canada and the U.S. has C demonstrated that “slims” brand descriptors are associated with increased brand appeal and M stronger beliefs that smoking is associated with thinness.109,115

CM The tobacco industry often claims that the use of descriptors such as low tar, “light” and “mild”

MY are not misleading. For example, a consumer research funded by Japan Tobacco International (JTI) conducted in Hong Kong (HK), Korea and Malaysia emphasized that “Mild Seven” is not CY misleading and that “virtually no one” believes that “light” and “mild” cigarettes pose less harm CMY than other products. However, when prompted further with statements about “less harm to K health”, (a) 35% in HK and Malaysia and 37% in Korea believe that some cigarettes are less harmful than others, (b) 27% in HK, 25% in Malaysia, and 34% in Korea believe that “some cigarettes described as “mild” pose lower health risks than other cigarettes,” and (c) 30% in HK and Malaysia and 36% in Korea believe that "some cigarettes described as “lights” and “super lights” pose lower health risks than other cigarettes.” The report also shows that some of those surveyed who smoke certain brands (such as Mild Seven) prefer them because of the lower tar or nicotine content or because they believe that a particular brand is “healthier” or less harmful than others.116

As discussed in Section 3, using numbers as a brand descriptor also constitutes a misleading practice and Article 11 Guidelines recommend that this practice be prohibited.

Current International Best Practice

To date, more than 50 countries have prohibited the terms “light”, “mild”, and “low tar”. The list of prohibited terms has been expanded in countries such as Malaysia, to include: “cool”, “extra”, “low tar”, “special”, “full flavor”, “premium”, “rich”, “famous”, “slim”, and “grade A”.

28 29.pdf 1 6/7/11 7:07 AM

4.4 Logos, Colours, and Indeed, as one moves down the delivery sector, then the closer to white a pack Brand Imagery: tends to become. This is because white is generally held to convey a clean Plain Packaging healthy association.”117 Different shades of the same colour and the proportion of white space on the package are Article 11 Guidelines commonly used to manipulate perceptions of a product’s strength and (Paragraph 46) potential risk. Indeed, a number of Parties should consider adopting measures to industry studies have shown that the restrict or prohibit the use of logos, colours, brand colour and design of the package are images or promotional information on packaging effective to the point where they influence other than brand names and product names sensory perceptions from smoking a displayed in a standard colour and font style (plain cigarette, a process known as “sensory packaging). This may increase the noticeability and transfer.”7,118,119 Research from other effectiveness of health warnings and messages, health domains underscores the effect of prevent the package from detracting attention from colour on consumer perceptions: the them, and address industry package design colour of pharmaceutical pills, for techniques that may suggest that some products example, has been shown to influence are less harmful than others. their effectiveness, presumably through C a potent placebo effect.120

Y References To Product Design

CM Products that are positioned as “low tar” MY brands targeted at health conscious CY smokers often carry images or CMY references to product design on the K package. References to filtration are among the oldest and most common examples of this strategy. For more than 50 years, tobacco companies have communicated filter properties to consumers as tangible evidence of Lighter colours tend to be used to 76 represent lower delivery products emissions reduction and lower risks. Indeed, the rise of filtered cigarettes in the U.S. paralleled the rise in health Evidence concerns among consumers. From Kent’s Micronite filter, to Barclay’s The persistence of false beliefs may also be due to ACTRON filter, to the charcoal filters other promotional aspects of the pack, including brand currently being test marketed in Marlboro imagery and colour.6,7 Tobacco industry documents describe this phenomenon: “Lower delivery products Ultra Smooth - whatever the filtration tend to be featured in blue packs.” properties of these designs may be, they reassure smokers when displayed on the package.121

29 As Myron Johnston and W.L. Dunn of Philip Morris stated in 1966, “the illusion of filtration is as important as the fact of filtration.”122 The image at left provides a contemporary example of this packaging strategy from China, where a leading brands feature images of high-tech filters and references to "colour cellulose particles.” Packages with pictures and references to special cigarette filters such as this are rated Pictures of ‘high tech’ by a majority of smokers as having less tar and lower health risk.56 These references filters are sometimes used to imply that the to product design and emissions on the package may be meaningless in terms of actual mainstream smoke is risk; however, the perception of improved filtration and technology has the potential to less hazardous falsely reassure consumers.

Plain Packaging The removal of colour and other elements of package design-so-called “plain packaging”-has emerged as one regulatory option for reducing potentially misleading package designs.123 Plain packaging would standardize the appearance of cigarette packages by requiring the removal of all brand imagery, including corporate logos and trademarks. Packages would display a standard background colour and manufacturers would be permitted to print only the brand name in a mandated size, font and position. Other government-mandated information, such as health warnings, would remain.

Plain Packaging Reduces False Beliefs About the Harmfulness of Difference Cigarette Brands C

M Adults and youth are significantly less likely to report false beliefs about the relative Light pastel Y risk of cigarette brands when viewing packs with the colour and brand imagery colours are 56,105 CM removed. Plain packaging has also been shown to reduce beliefs about the link used for cigarette MY between smoking and weight control. In a recent study conducted among young packs meant

CY women in Canada, women who viewed eight female-oriented packs with colours for women

CMY such as pink, were significantly more likely to report that smoking “helps people stay 109 K slim” than women who viewed “plain” versions of the same packs.

Plain Packaging Increases the Effectiveness of Health Warnings

Plain packaging may also enhance the effectiveness of health warnings by increasing their noticeability, recall, and believability.124-127 For example, in one study, New Zealand youth were significantly more likely to recall health warnings when they were presented on plain packs compared to health warnings presented on “normal” branded packages.125

Plain Packaging Reduces Brand Appeal Among Children and Youth

Plain packaging regulations also have the potential to satisfy more general marketing restrictions and reduce tobacco marketing to children and youth. Brand descriptors and imagery are particularly important marketing strategies for targeting youth and younger adults.6,128-130 Packaging design is critical to establishing brand appeal and identity among youth, the period in which brand preferences are established.7 Lipstick pack with slim Research to date suggests that plain packages are less attractive and engaging, and cigarettes for women may reduce the appeal of smoking among youth and adults, including for brands targeted at women.15,131-134

30 31.pdf 1 6/7/11 7:08 AM

Standardizing Package Shape and Size

Pictorial health An additional component of “plain” packaging could include regulations on warning is proportionately the shape and size of packages. Tobacco manufactures have released an reduced in size increasing number of “special edition” packages, many of which have novel for lipstick pack shapes and open in different ways.135 Novel shapes and sizes may also increase the appeal of cigarette brands and may be particularly engaging to youth. In particular, “slim” packages used to market female brands may promote the widespread belief that smoking is an effective way to stay thin and control weight-an important predictor of tobacco use among girls.109,110,136 Different shapes and sizes also have the potential to undermine health warnings on packages. In some cases, packages are so small and narrow that they either warp the health warning pictures or render the text so small as to be unreadable. Additional research on the potential impact of standardizing pack shape and size should be considered a priority.

Current International Best Practice

M Australia is the first country to announce plain packaging regulations prohibiting colour, logos and

Y brand imagery on packages. Starting July 1, 2012, tobacco products will be sold in packs with a

CM standardized background colour and promotional text will be restricted to brand and product names

MY in a standard colour, position, type style and size.

CMY

K 4.5 Expiry Date

Article 11 Guidelines (Paragraph 45)

Parties should prevent the display of expiry dates on tobacco packaging and labeling where this misleads or deceives consumers into concluding that tobacco products are safe to be consumed at any time.

An expiry date commonly means that a product is safe to consume prior to its expiry date. Given the inherent harm of tobacco use, such as with poisons and other toxic commercial products, no safety can be implied, and hence the application of an expiry date should be prohibited. Fortunately, no country in Southeast Asia currently requires the printing of an expiry date on tobacco packages. Additional information that is printed on Malaysia cigarette packs includes the manufacture/importation date (Day/Month/Year) and the manufacturer’s/importer’s name and address.

31 LEGAL MEASURES and 5 ENFORCEMENT

Article 11 Guidelines (Paragraphs 47-65)

LEGAL MEASURES Drafting In drafting legal measures with respect to tobacco product packaging and labelling, Parties should consider issues such as who will be responsible for their administration, the available approaches for ensuring compliance and enforcement, and the level or levels of government involved. Administration Parties should identify the authority or authorities responsible for overseeing implementation of tobacco product packaging and labelling measures. Parties should consider ensuring that the relevant authority responsible for tobacco control matters is the same as that which administers the legal measures. In the event that the administration is made the responsibility of another area of government, the relevant health authority should provide input into label specifications. Scope Parties should ensure that the packaging and labelling provisions related to Article 11 of the Convention apply equally to all tobacco products sold within the jurisdiction, and that no distinction is made between products that are manufactured domestically or imported or intended for duty-free sale within a Party’s

C jurisdiction. Parties should consider circumstances in which measures would apply to exported products.

M Costs Parties should ensure that the cost of placing health warnings and messages, as well as information on Y constituents and emissions, on tobacco product packaging is borne by the tobacco industry. CM Liability MY Consistent with Article 19 of the Convention, Parties should consider including provisions to make it clear

CY that the requirement to carry health warnings and messages or to convey any other information about a tobacco product does not remove or diminish any obligation of the tobacco industry, including, but not CMY limited to, obligations to warn consumers about the health hazards arising from tobacco use and exposure K to tobacco smoke. Specific Provisions Parties should ensure that clear, detailed specifications are provided for in their legal measures in order to limit the opportunity for tobacco manufacturers and importers to deviate in the implementation of health warnings and messages, as well as to prevent inconsistencies among tobacco products. In drafting such measures, Parties should review, inter alia, the following list: ■ packaging and products (please refer to paragraph 37); ■ language(s) to be used in mandated text of health warnings and messages and in information on constituents and emissions on packaging, including how languages should appear if there is more than one language; ■ rotation practice and time frames, including the number of health warnings and messages to appear concurrently as well as specifications of transition periods and deadlines within which the new health warnings and messages must appear; ■ distribution practices, in order to obtain equal display of health warnings and messages on retail packages, not just for each brand family but also for each brand within the brand family for each package size and type; ■ how text, pictures and pictograms of health warnings and messages should actually appear on packaging (including specification of location, wording, size, colour, font, layout, print quality), including package inserts, onserts and interior messages; ■ different health warnings and messages for different types of tobacco product, where appropriate; - source attribution, if appropriate, including placement, text and font (similar detailed specifications as for the health warnings and messages themselves); and ■ prohibition of promotion by means that are false, misleading, deceptive or likely to create anerroneous impression, in accordance with Article 11.1(a) of the Convention. Source Document Parties should consider providing a “source document”, which contains high-quality visual samples of how all health warnings and messages and other information are to appear on packaging. A source document is particularly useful in the event that the language used in the legal measures is not sufficiently clear.

32 Adhesive Labels and Covers Parties should ensure that adhesive labels, stickers, cases, covers, sleeves, wrapping and tobacco manufacturers’ promotional inserts and onserts do not obscure, obliterate or undermine health warnings and messages. For example, adhesive labels might be allowed only if they cannot be removed and are used only on metal or wood containers that hold products other than cigarettes. Legal Responsibility for Compliance Parties should specify that tobacco product manufacturers, importers, wholesalers and retail establishments that sell tobacco products bear legal responsibility for compliance with packaging and labelling measures. Penalties In order to deter non-compliance with the law, Parties should specify a range of fines or other penalties commensurate with the severity of the violation and whether it is a repeat violation. Parties should consider introducing any other penalty consistent with a Party’s legal system and culture that may include the creation and enforcement of offences and the suspension, limitation or cancellation of business and import licenses. Enforcement Powers Parties should consider granting enforcement authorities the power to order violators to recall non-compliant tobacco products, and to recover all expenses stemming from the recall, as well as the power to impose whatever sanctions are deemed appropriate, including seizure and destruction of non-compliant products. Further, Parties should consider making public the names of violators and the nature of their offence. Supply Deadline In order to ensure the timely introduction of health warnings and messages, legal measures should specify a single deadline by which manufacturers, importers, wholesalers and retailers must only supply tobacco products that comply with the new requirements. The time allocated need only be enough to allow manufacturers and importers to organize the printing of new packages. It has been considered that a period of up to 12

C months from the enactment of the legal measures should suffice in most circumstances.

M Review Parties should recognize that the drafting of legal measures for packaging and labelling of tobacco products Y is not a one-time exercise. Legal measures should be reviewed periodically and updated as new evidence CM emerges and as specific health warnings and messages wear out. When undertaking periodic reviews or

MY updates, Parties should take into account their experience in using their packaging and labelling measures, the experiences of other jurisdictions, as well as industry practices in this area. Such reviews or updates can CY help identify weaknesses and loopholes and highlight areas in which the language used in the measures

CMY should be clarified.

K ENFORCEMENT Infrastructure and Budget Parties should consider ensuring that the infrastructure necessary for compliance and enforcement activities exists. Parties should also consider providing a budget for such activities. Strategies To enhance compliance, Parties should inform stakeholders of the requirements of the law before it comes into force. Different strategies might be required for different stakeholders, such as tobacco manufacturers, importers and retailers. Parties should consider using inspectors or enforcement agents to conduct regular spot checks of tobacco products at manufacturing and importing facilities, as well as at points of sale, to ensure that packaging and labelling comply with the law. It may not be necessary to create a new inspection system if mechanisms are already in place that could be extended to inspect business premises as required. Where applicable, stakeholders should be informed that tobacco products will undergo regular spot checks at points of sale. Response to Non-Compliance Parties should ensure that their enforcement authorities are prepared to respond quickly and decisively to instances of non-compliance. Strong, timely responses to early cases will make it clear that compliance is expected and will facilitate future enforcement. Parties should consider making the results of enforcement action public in order to send a strong message that non compliance will be investigated and action will be taken. Complaints Parties should consider encouraging the public to report violations in order to further promote compliance with the law. It might be helpful to establish an enforcement contact point for reporting alleged cases of non-compliance. Parties should ensure that complaints are investigated and dealt with in a timely and thorough manner.

33 34.pdf 1 6/7/11 7:10 AM

In developing laws and regulations on tobacco packaging and labeling, Parties should be as prescriptive and detailed as possible to avoid exploitation of any legal loopholes by the tobacco industry that could result in ineffective regulation. Consideration should be given to the measures described in the preceding sections, as well as to providing a source document, strict compliance deadlines, and appropriate penalties for non-compliance.

A “source document” contains high-quality visual samples of how health warnings and messages and other information are to appear on packaging. It is particularly useful to prevent misinterpretation by the tobacco industry when the language used in the law or regulation is not sufficiently clear.

Parties should set realistic implementation timelines and compliance deadlines for the tobacco industry when introducing new or modified packaging and labeling requirements in a country. It is essential to have one implementation date that would apply to all levels of the supply chain: manufacturers/importers, wholesalers and retailers. At the manufacturer/importer level, the transition period should not be longer than one year from the date of passing of the law/regulation, since this is an achievable timeframe that is proven by many countries. A shorter transition period is possible and preferable.

Timeline for implementing pictorial health warnings (PHWs) in selected countries:

+ Singapore (50% front and back): 9 months for first set; only 5 months for second set; C Singapore was the third country in the world to require PHWs

M + Thailand (50% front and back): 12 months for the first set in 2005, when Thailand was only Y the 4th country to implement PHWs); only 6 months for the second and third sets CM implemented in 2006 and 2009 respectively

MY + Brunei (50% front and back): 12 months CY + Malaysia (40% front and 60% back): 4 months (but companies successfully lobbied for some CMY latitude: 2 brands with PHWs in 4 months, all brands after another 5 months) K + Mauritius (65% front and back): 3.5 months

There should be a ban on manufacturing, distribution, and sale of products with old package labels after the implementation date. This prevents manufacturers from stockpiling products with old packaging. Furthermore, if a manufacturer, distributor, wholesaler or retailer displays or sells non-compliant products beyond the implementation date, all such products should be subject to seizure and other appropriate penalties by enforcement officials.

34 35.pdf 1 6/7/11 7:12 AM

COUNTERING TOBACCO INDUSTRY ARGUMENTS: 6 THE FACTS

The tobacco industry has generally opposed the introduction of large pictorial health warnings on packages.137 For example, in 1995, package warnings were identified by British American Tobacco as one of the key issues facing the company.138 Protecting the pack design and “neutralizing” the controversy over pack warning labels were among the priorities listed in the document.139 The same document goes on to state that, “pictorial warnings, and those occupying a major pack face or faces (front and back) or a disproportionately large area of advertising space, should be restricted, as should moves to plain or generic packs. Every effort should be made to protect the integrity of the company's packs and trade marks.”113

In public, tobacco manufacturers have argued that large comprehensive warnings are not only unnecessary, but are less effective than text messages.138 For example, Martin Broughton, the former Chairman of BAT, recently stated that: “The growing use of graphic image health warnings …can offend and harass consumers- yet in fact give them no more information than print warnings.” Tobacco manufacturers have also argued that comprehensive warnings 7 C constitute an unreasonable and illegal expropriation of cigarette packaging.

Y Although tobacco manufacturers have launched legal challenges in countries such as Canada

CM and the European Union, health warning legislation was upheld by the courts in both cases.

MY Although legal challenges are relatively rare, Parties should be prepared to counter common

CY grounds of opposition. The section below summarizes common industry arguments.

CMY

K 1. Industry Myth “Smokers are adequately informed about the health risks of smoking.” Facts

Smoking causes more than two dozen health effects and one out of every three long-term smokers will die from tobacco use. Very few, if any, smokers are aware of the full range of health effects and most underestimate the severity of these health risks, even in highly-educated countries. Health warnings have been proven to increase awareness of health effects among youth and adults. Even among groups who report high levels of health knowledge, vivid health warnings increase the frequency with which smokers think about the health risks and promote quitting behaviour. It is also important to recognize that children and youth are a primary target of health warnings. Large picture-based warnings can be understood by young children and, in countries with large graphic warnings, young people report very high levels of awareness of health warnings.

35 2. Industry Myth “Neither larger warnings nor the use of pictures will be any more effective than the existing textual warnings.” Facts

Research conclusively demonstrates that picture warnings are more effective than text-only messages. The use of pictorial symbols is a common and effective feature of health warnings for a wide variety of consumer products.88-93,140 Health warnings with pictures are significantly more likely to draw attention and result in greater processing, and memory of the accompanying text. Picture warnings also encourage individuals to imagine health consequences and are more likely to be accessed when an individual is making relevant judgments and decisions. Experimental research, market-research, and large population-based surveys in countries that have implemented picture warnings all demonstrate that graphic warnings are more likely to be noticed and read by smokers, and are associated with stronger beliefs about the health risks of smoking, as well as increased motivation to quit smoking.27,30,31,33,34,38,39,52-56,72,141

Picture-based warnings are essential in communicating health information to people with lower literacy rates.58-60 This is particularly important considering that, in most countries, smokers report lower levels of education than the rest of the population. Picture warnings can be understood by those who speak different languages, as well as by youth and young

C children who may not be able to read.

Y CM 3. Industry MY Myth “There is no serious evidence that the warnings have CY any real impact on tobacco usage.” CMY Facts

K Health warnings can promote cessation behavior and larger pictorial warnings are most effective in doing so. Significant proportions of adult and youth smokers report that large comprehensive warnings have reduced their consumption levels, increased their likelihood of quitting, increased their motivation to quit, and increased their likelihood of remaining abstinent following a quit attempt.37,39,45,46,142-149 At least three longitudinal studies-two with adults and one with youth-have demonstrated an association between viewing and thinking about health warnings and subsequent cessation behavior, one of which was conducted with nationally representative samples of smokers in Canada, Australia, the UK and the US.56,60 Increases in the use of cessation services have also been associated with health warnings. Research conducted in the UK, the Netherlands, Australia, and Brazil has examined changes in the usage of national telephone “helplines” for smoking cessation after the contact information was included in package health warnings. Each of these studies reports significant increases in call volumes.66,150,151 For example, calls to the toll-free smoking cessation helpline in the Netherlands increased more than 3.5 times after the number was printed on the back of one of 14 package warnings.

36 4. Industry Myth “Health warnings do not deter youth from starting.” Facts

Large pictorial warnings are especially effective among youth. Population-based surveys indicate that significant proportions of youth non-smokers, including the most vulnerable youth populations in Canada, the UK, and Australia49 report that warnings have discouraged them from smoking. Between one-fifth and two-thirds of youth non-smokers indicated that the warnings had ‘helped them from taking up smoking’ in Canada and Australia, and approximately 90% of youth non-smokers in a national UK survey reported that the warnings “put them off smoking.” Longitudinal surveys in Australia have also found that experimental and established smokers were more likely to think about quitting and forgo cigarettes after the implementation of large pictorial warnings, while intention to smoke was lower among youth who had talked about the warning labels.49 Finally, nationally representative surveys conducted in 2008 with over 26,000 respondents from 27 EU member states and Norway found that 3 out of 10 non-smokers in the EU reported that health warnings are effective in preventing them from smoking. Levels were highest in Romania, where pictorial warnings were implemented shortly before the survey was conducted, with 6 in 10 non-smokers reporting that the warnings have helped to prevent them from smoking.Large picture health

C warnings can also reduce a brand’s appeal among youth and the impact of package displays 152,153 M at retail outlets to which children are frequently exposed. Overall, all of the evidence

Y conducted to date suggests that comprehensive health warnings help to prevent smoking

CM initiation, and that larger pictorial warnings are most effective in doing so.

CMY

K 5. Industry Myth “FCTC does not require parties to implement pictorial health warnings.” Facts

The original text in FCTC Article 11 states that Parties “may” use pictorial warnings. However, the Guidelines for Article 11- guidelines that are intended to explain and assist implementation of the Articles - state that “pictures are superior” and that Parties should consider adopting pictures. The revised language in the Guidelines reflect the broader adoption of pictorial warnings around the world as well as the growing evidence base that has clearly demonstrated the superiority of pictorial warnings over text warnings.

37 38.pdf 1 6/7/11 7:13 AM

6. Industry Myth “There is no need for mandatory warnings.” Facts

Virtually every jurisdiction in the world has some form of mandatory warning label and Article 11 of the WHO FCTC treaty requires mandatory warnings. Voluntary warnings are typically far weaker than mandatory warnings, and mandatory regulations ensure that all consumers are receiving the same level of health information on packages.

7. Industry Myth “There is no need to introduce new warnings or pictorial warnings.” Facts

Like any advertising or health communication, health warnings must be regularly updated to maintain their maximum impact over time. Picture warnings appear to sustain their impact longer than text-warnings, but all warnings should be “refreshed” with new messages and pictures every two to four years. When

C developing new warnings some regulators plan ahead and develop multiple sets

M of warnings that will be rotated after a set time period.

CM MY 8. Industry CY Myth “Mandatory health warnings constitute an expropriation of CMY the tobacco industry’s packages and trademarks and are

K an assault on free enterprise and the national economy.” “The Ministry of Commerce is worried about violation of intellectual property rights.” Facts

Tobacco companies have argued that pictorial warnings represent an unjustified expropriation of the pack and violate intellectual property rights. In jurisdictions such as Canada, the European Union, Brazil, and India the tobacco industry has challenged the government’s right to impose pictorial warnings. In all of these cases, the courts have upheld the government’s right to impose pictorial warnings. Indeed, the tobacco industry has yet to mount a successful legal challenge to prevent pictorial warnings. For example, in response to a legal challenge of the Canadian Tobacco Act, the court found that the tobacco companies’ right to advertise their products could not be given the same legitimacy as the federal government’s duty to protect public health. In short, the courts have ruled that graphic warnings are warranted considering the societal costs of smoking. Manufacturers in the European Union have also argued that the labelling directive infringed on Article 20 of the Agreement on the Trade-related Aspects of Intellectual Property Rights (‘the TRIPs Agreement’) as set out in the WTO Agreement. The European Court of Justice dismissed this argument and upheld the labelling law.

38 9. Industry Myth “The warnings ‘demonize’ smokers and make them feel like outcasts.” Facts

Tobacco manufacturers commonly portray more comprehensive health warnings as an example of the government attacking or harassing smokers. In fact, there is evidence from a number of countries that large pictorial warnings are not only supported by a strong majority of non-smokers, but also by most smokers. Indeed, many smokers welcome more health information on their packages, particularly when it includes support for quitting. In addition, support for large pictorial warnings typically increases after they have been implemented and increases over time. Therefore, industry claims that comprehensive warnings represent government attacks on smokers are not shared by most smokers themselves.

10. Industry Myth “Pictorial warnings are too morbid and socially unacceptable.” Facts

C Every jurisdiction has the freedom to select the images that will appear on packages M and can ensure that warnings are culturally appropriate. Smokers themselves Y consistently select the graphic depictions of health effects and fear-arousing images CM as the most effective health warnings. In every survey that has been conducted MY to date, strong majorities of the public support large graphic warnings, including CY a majority of smokers themselves. Although these images may be unpleasant to CMY look at, they accurately and truthfully depict the health consequences of smoking.

11. Industry Myth “If the government wants to put out those messages, it should use billboards or tv commercials.” Facts

Anti-smoking messages using billboards and TV can be a very effective tobacco control measure. However, advertising through these channels can be very costly and requires resources and planning to sustain. In contrast, cigarette health warnings cost governments very little or nothing to implement, and are self-sustaining. Cigarette packages also provide unique reach and frequency of exposure: pack-a-day smokers are potentially exposed to the warnings over 7,000 times per year, including at the time of sale and with each smoking act. Finally, health warnings also fulfill a government’s responsibility to provide adequate warnings for consumer products that kill half of all long term users.

39 12. Industry Myth “It is expensive and technically difficult to design new, pictorial based health warning labels, especially for small companies and home industries.” Facts

Tobacco manufacturers have previously argued that they lack the technology to print colour pictorial warnings or that the costs of altering their existing printing methods would be prohibitive. Although manufacturers must bear the costs of redesigning their printing practices, such as the costs of re-etching press cylinders or preparing new lithographic printing plates, the technology required to print colour warnings is widespread. Small companies and “home industries” also have several options, including printing health warnings on stickers or adhesive labels that can be permanently applied to a variety of packages that are manufactured to a lower standard. This approach has been used in India, where many packages are sold in plastic wrapping, rather than carefully manufactured packages.

13. Industry Myth “It is too expensive and technically difficult for us to keep C changing the warning labels on tobacco packaging.” M Facts

CM Regulations requiring new health warnings typically include advance notice to allow

MY manufacturers to make the necessary preparations for the new warnings. For example,

CY many jurisdictions give the industry 6 or 12 months notice following the official

CMY announcement of new regulatory standards. In addition, regulators can reduce the

K burden on manufacturers by providing specific provisions and supplying manufacturers with high quality images of the new warnings.

14. Industry Myth “Printing pictorial health warnings is not feasible in developing countries.” Facts

Low and middle income countries were among the first to implement pictorial warnings. In addition, the vast majority of brands sold in low and middle income countries are owned by large multinational tobacco companies, who already manufacture packages with pictorial warnings in dozens of jurisdictions throughout the world.

40 15. Industry“Only a few countries have implemented pictorial Myth health warning regulation so far, most of which are developed countries. It is unnecessary that our country be the pioneers in this field.” Facts

Approximately half of all countries that require picture warnings are low and middle income countries. Picture health warnings are no longer “novel” or “cutting edge” policies; rather, they have become the basic standard for package warning labels internationally. There is also evidence that picture warnings are even more effective in low and middle income countries, particular in countries with lower levels of literacy. Text-only health warnings have little or no effect among those who cannot read. This includes illiterate individuals, individuals who may be literate but in a language other than that used for text warnings, as well as young children. The most effective way to reach low-literacy smokers is to include pictures, which can be universally understood. This is especially important when considering the effectiveness of health warnings among young children, few of whom may be able to read. Thus, large pictorial health warnings may be even more effective in low and middle income countries.

C M Industry Y 16. Myth “Countries should move step by step to implement CM text warnings first and then change to pictorial

MY health warnings.”

CY Facts

CMY Given that pictorial health warnings are superior to text warnings, there is K no rationale for delaying their implementation. Delaying the implementation of pictorial warnings withholds the best quality health information from tobacco consumers and the public.

17. Industry Myth “Pictorial health warnings will lead to more smuggling.” Facts

There is no evidence that graphic health warnings have lead to an increase in smuggling in any jurisdiction. In fact, large picture warning may help to reduce smuggling: because each country has a unique set of warnings, large picture warnings make contraband cigarettes easier to identify in most cases.

41 18. Industry“Pictorial health warnings will increase the price of Myth cigarettes, cause massive job losses, and hurt government revenue.” Facts

There is no evidence from the dozens of countries that have implemented graphic health warnings to date that pictorial warnings increase cigarette prices, lead to job losses, or hurt government revenue. Comprehensive picture warnings do have the potential to increase quitting, but no single measure is capable of massive, sudden declines in tobacco prevalence in a manner that would lead to massive job losses. To the extent that tobacco companies experience reduced revenue due to comprehensive health warnings, these reductions will be offset by improvements in population level health, reduced health care expenditures and greater productivity of workers.

19. Industry“Many countries require tar, nicotine, and carbon Myth monoxide measurements to be printed on packs, our government should do it also.” C Facts M

Y The emission numbers printed on packages are the same numbers that tobacco CM companies have used in misleading advertising that markets “low tar” cigarettes as an MY alternative to quitting. Printing emission numbers on packages reinforces this deceptive CY marketing campaign and the false belief that low tar cigarettes are less hazardous: CMY there is no association between the machine-generated emission numbers printed on K packages and the health risk of different brands. Therefore, regulations that require emission numbers to be printed on packages are not only ineffective, but harmful regulatory practices. Scientific bodies, including the World Health Organization’s scientific group on tobacco product regulation, have called for the removal of emission numbers from packages. A growing number of countries have removed tar and nicotine numbers from packs, including Australia, Thailand, and others. Countries such as Canada and the European Union have also signaled their intention to do the same.

42 20. Industry“Printing tar and nicotine yields will allow smokers Myth to choose brands with higher or lower yields as they desire.” Facts

The majority of smokers who use tar and nicotine numbers to choose brands do so in the false belief that these brands may be less harmful than “regular” or “higher tar” brands. There are many other brand elements that smokers can use to select brands. Indeed, in countries such as the United States, where tar and nicotine numbers are not required on packs, very few companies choose to print these numbers voluntarily.

21. Industry Myth “Requiring the printing of ingredients is a violation of trade secrecy rights.” Facts

To date, no countries require a full list of ingredients to be printed on packs, in part because

C tobacco contains thousands of chemicals and a long list of ingredients. FCTC Articles 9

M and 10 are developing new guidelines for mandatory reporting of tobacco ingredients to

Y regulators, as well as recommendations for communicating this information directly to

CM consumers.

CMY

43 HEALTH WARNINGS IN THE SOUTHEAST ASIA 7 REGION

Brunei

With reference to Tobacco Order 2005 (S49/05) and the 2007 Tobacco Labelling Regulations all tobacco products sold in Brunei are required to carry one of six rotating pictorial health warnings occupying the upper 50% of the front and back of the pack beginning December 2008.154 The health warnings must be printed in both Malay and English language on the front and back panels of the pack. Information on tar level and nicotine content is required to be printed on the pack. The six health warning messages are:

Front Back C

M 50% of the 50% of the Y upper front upper back

CM panel panel

CMY

Smoking Causes Lung Cancer

44 Cambodia

The health warning sub decree155 that was passed in October 2009 has stipulated that health warning messages shall cover at least the bottom 30% of the front and back of the pack. It must be printed in the Khmer language on both sides of cigarette pack. There are five health warning messages as follows:

+ Smoking causes Lung Cancer + Smoking causes Stroke

+ Smoking causes Emphysema + Smoking causes Tooth Decay

+ Smoking causes Heart Diseases

C 30% of the 30% of the

M bottom bottom back front panel panel Y

CM Smoking Causes Lung Cancer MY

CMY

Indonesia Front Back

Based on Government Regulation (PP) 19/2003 article 9156, a textual health warning is required to be printed on the bottom of the back of each cigarette pack with only one authorized textual health warning that states “Smoking can 10% of the bottom back panel of the cause cancer, heart attack, impotence pack and harms pregnancy and foetal development”. It must apply to all forms Smoking can cause cancer, of advertisements including billboards. heart attack, impotence and harms pregnancy and foetal development

45 Laos

In May 2006, the Ministry of Health157 approved a new decree on six rotating textual health messages in compliance to FCTC requirement. The health warning should be printed in the Lao Language and cover the upper 30% of the front and back of the pack. The health messages are as follows:

+ Smoking causes lung cancer + Smoking causes mouth cancer + Smoking causes heart failure + Smoking can kill people near you + Smoking causes brain hemorrhages + Smoking causes mouth stink/ bad breath

Although there is a decree in place, the tobacco manufacturers have not been compliant with the decree and claimed that it is not law. As a result, the tobacco industry could get around the decree that required them to print health warning messages on the packs. It was observed that there are health warnings printed in English language on both imported and locally produced cigarette packs although the regulation has indicated it should be written in Lao language.

Current Health Warning on Most Popular Brand

Local Cigarette Front Side

M Smoking Health Y is harmful messages printed in CM to health English MY language

CMY Adeng brand Dok Mai Deng brand K

Imported Cigarette Front Back

30% of the bottom front and back panel of the pack

Mock Up of Health Warnings As Required by Ministry of Health Decree Cigarette smoke causes cancer 30% of the upper front panel of the pack

46 Malaysia

According to the Control of Tobacco Products Regulations (Amendment 2008)158, starting from January 2009 cigarette packs in Malaysia are required to carry one of six rotating pictorial health warnings covering the upper 40% of the front and 60% of the back of the pack. The health warnings must be printed in Malay and English language on front and back panels of the pack. The six rotating health warning messages are:

Front Back

40% of the upper front 60% of the panel upper back panel

C Cigarette Causes Mouth Cancer

CMY

47 Myanmar Front Side

“The Control of Smoking and Consumption of Tobacco Product Law” was enacted in 2006. The law has a provision on packaging and labelling of tobacco products requiring textual health warning on the side of cigarette pack. The health warning must be printed in Myanmar language which says "Smoking can seriously affect health”.159 Smoking can seriously affect health

Philippines

In addition to the text warnings required by the Tobacco Regulation Act of 2003 (RA9211), Department of Health (DOH) Administrative Order No. 2010-0013160 has stipulated that nine rotating pictorial health warnings should be printed in English or Filipino languages on all tobacco packs. They must cover 30% of the top-front of the display panel on the pack, and 60% of the top-back of the pack. The image below shows the text warnings currently on packages, with the pictorial warnings not yet implemented. Implementation of pictorial health warnings has

C been delayed by multiple court cases filed by tobacco companies to stop DOH from enforcing

M its administrative order.

CMY

Front Back The current textual health messages are:

+ Government warning: Cigarettes smoking is dangerous to your health + Government warning: Cigarettes are addictive 30% of the + Government warning: Tobacco can bottom front harm your children panel only + Government warning: Smoking kills

48 Singapore

Singapore was the third country in the world and the first country in the ASEAN region to implement pictorial health warnings in 2003. According to Control of Advertisements and Sale of Tobacco (Labelling) Regulations 2003161, starting from July 1, 2004, all cigarette packages are required to display one of six rotating, clear and vivid pictorial health warning messages. The pictorial health warnings should occupy at least 50% of the upper front and back panels of the pack. In strengthening the tobacco control law on health warning policy, a new set of six tested and rotated graphic health warnings with stronger messages were introduced and came into effect on October 1, 2006.

The current graphic health warning messages are as follows:

Front Back

50% of the 50% of the upper front upper back panel panel

CY Smoking causes 92% of Oral Cancer

CMY

49 Thailand

Thailand became the fourth country in the world and second country in the ASEAN region to mandate pictorial health warnings effective 25th March 2005. The regulations issued under the Tobacco Product Control Act162 stipulates that all cigarette packages should carry one of 6 rotating pictorial health warnings covering the upper 50% of the front and back of the pack. The pictorial health warnings should be printed in Thai language. A third set of ten tested, rotated, clear and visible pictorial health warnings were introduced and took effect in March 2010. The current ten rotating pictorial health warnings occupying upper 55% of the front and back panels are shown below:

Front Back

55% of the 55% of the upper front upper back panel panel

Y Smoking Causes Gangrene CM

CMY

Smokers Die From Cigarette Smoke Kills Smoking Causes Death Cigarette Causes Cigarette Causes Stroke Those Nearby From Heart Attack Lung Cancer Foul Breath

Smoking Causes Mouth Smoking Causes Smoking Causes Throat Smoking Causes Cigarette Causes Cancer Emphysema Cancer Gangrene 10 Different Kinds of Cancer

50 Vietnam

To advance the health warnings policy in Vietnam, the Minister of Health issued a government decree No 119/2007 ND-CP163 in 2007. The decree stipulates that beginning April 2008, the health warnings should cover the bottom 30% of the front and back of the pack with the health messages printed in Vietnamese saying “Smoking can cause lung cancer” or “Smoking can cause Chronic Obstructive Pulmonary Disease (COPD)”. The health messages will be rotated every two years.

Front Back

30% of the 30% of the bottom front bottom back panel panel

SmSmoking Can Causee Lung Cancer

CMY K HEALTH WARNINGS IN ASEAN

51 52.pdf 1 6/7/11 7:16 AM

ADDITIONAL REFERENCES AND SOURCES OF 8 EVIDENCE

Tobacco Labelling Resource Overview http://www.tobaccolabels.ca/ Picture health warnings and regulations from around the world http://www.tobaccolabels.ca/healthwarningimages Summary of Evidence http://www.tobaccolabels.ca/healthwarningsinfo Recommendations for design warnings and drafting regulations http://www.tobaccolabels.ca/toolkit

WHO Framework Convention on Tobacco Control Overview C http://www.who.int/fctc/en/index.html

M FCTC Articles

Y http://www.who.int/fctc/text_download/en/index.html Article 11 Guidelines on Packaging and Labelling CM http://www.who.int/fctc/guidelines/article_11/en/index.html MY

CY World Health Organization CMY

K Tobacco Free Initiative http://www.who.int/tobacco/en/ WHO Report on Health Warning Messages http://www.who.int/tobacco/wntd/2009/en/index.html

Southeast Asia Tobacco Control Alliance (SEATCA) Overview www.seatca.org + It’s Only Words: Interference in Implementing Health Warnings in Cambodia + Implementing Pictorial Health Warnings in Malaysia: Challenges and Lessons Learned + Asia-Pacific Report Card: WHO FCTC Articles 5.3,6,8,11 & 13

Physicians for a Smoke-free Canada Overview http://www.smoke-free.ca

52 9 REFERENCES

1 World Health Organization. (2008). WHO Report on the Global Tobacco Epidemic 2008: The MPOWER Package. Geneva, World Health Organization, 2008.

2 Shapiro SJ, Perreault WD, McCarthy EJ. (1999). Basic Marketing: A Global Managerial Approach. Toronto: McGraw-Hill; 1999.

3 Slade J. (1997). The Pack As Advertisement. Tobacco Control. 1997;6:169-170.

4 Underwood RL, Ozanne J. (1998). Is Your Package An Effective Communicator? A Normative Framework for Increasing the Communicative Competence of Packaging. Journal of Marketing Communication. 1998;207-20.

5 Palmer A. (2000). The Product. Principles of Marketing. Oxford: Oxford University Press/Books; 2000. p. 215-38.

6 Pollay RW. (2001). The Role of Packaging Seen Through Industry Documents. Mar 2001. Expert Report prepared for: JTI-Macdonald., Imperial Tobacco Canada Ltd and Rothmans, Benson & Hedges Inc. v. Attorney General of Canada and Canadian Cancer Society (intervenor). Supreme Court, Province of Quebec, District of Montreal. Defense Exhibit D-116.

7 Wakefield M, Morley C, Horan JK, Cummings KM. (2002). The Cigarette Pack as Image: New Evidence from C Tobacco Industry Documents. Tobacco Control. 2002 Mar;11(Suppl 1):i73-i80.

M 8 Federal Trade Commission Cigarette Report for 2004 and 2005[Internet]. 2007 [cited 2008 May 15]. Available from: Y http://www.ftc.gov/reports/tobacco/2007cigarette2004-2005.pdf

CM 9 Dewhirst T. (2004). POP Goes The Power Wall? Taking AimAt Tobacco Promotional Strategies Utilised At Retail.

MY Tobacco Control. 2004;13:209-210.

CY 10 Wakefield MA, Terry-McElrath YM, Chaloupka FJ, et al. (2002). Tobacco Industry Marketing At Point of Purchase

CMY after the 1998 MSA Billboard Advertising Ban. American Journal of Public Health. 2002; 92:937–40.

11 K Environics Research Group Limited. The Health Effects of Tobacco and Health Warning Messages on Cigarette Packages—Survey of Adults and Adults Smokers: Wave 9 Surveys. Ottawa: Health Canada; 2005 Jan.

12 Wakefield M, Letcher T. (2002). My Pack Is Cuter Than Your Pack. Tobacco Control. 2002;11:154-156.

13 Carter SM. (2003). Going Below the Line: Creating Transportable Brands for Australia’s Dark Market. Tobacco Control. 2003;12 (Suppl 3):iii87-iii94.

14 Hulit M. (1994). Marketing issues corporate affairs conference May 27, 1994—Manila [Internet]. Richmond (VA): Philip Morris. 1994 May [Cited 2008 May 15]. Bates No. 2504015017/5042. Available from: http://legacy.library.ucsf.edu/tid/jga42e00.

15 Hammond D, Fong GT, Borland R, McNeill A, Cummings KM, Hastings G. (2006). Effectiveness of Cigarette Warning Labels in Informing Smokers about the Risks of Smoking: Findings from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control. 2006;15(Suppl III):iii19–iii25.

16 Brown KS, Diener A, Ahmed R, Hammond D. (2008). Survey Methods. 2002 Youth Smoking Survey Technical Report [Internet]. Ottawa: Health Canada; 2005 [Cited 2008 May 15]. Available from: http://www.hc-sc.gc.ca/hl-vs/pubs/tobac-tabac/yss-etj-2002/index_e.html .

17 Fong GT, et al. (2007). International Tobacco Control Policy Evaluation Survey: ITC South East Asia Survey; 2007.

18 Aftab M, Kolben D, Lurie P. (1999). International Cigarette Labelling Practices. Tobacco Control 1999; 8(4): 368-72.

19 World Health Organization. (2003). WHO Framework Convention on Tobacco Control. World Health Organization, Geneva, Switzerland.

53 54.pdf 1 11/21/10 11:48 AM

20 World Health Organization. (2008). Guidelines for Implementation of Article 11 of The WHO Framework Convention on Tobacco Control (Packaging And Labelling of Tobacco Products). November, 2008. Available at: http://www.who.int/fctc/guidelines/article_11.pdf

21 Norman C. (2008). Graphic Health Warnings – Singapore’s Experience.Paper presented at Regional Meeting on Implementation of WHO-FCTC Article 11 (Tobacco Packaging and Labeling), 20-21 May 2008, Kuala Lumpur, Malaysia.

22 Adam S. (2010). Tobacco – Australia Plans To Introduce Generic Packaging. Citigroup Global Markets, 28 April 2010.

23 Cragg, Ross, & Dawson Ltd. (1990). Health Warnings on Cigarette and Tobacco Packs: Report on Research to Inform European Standardization. London, Dec 1990.

24 Health Education Authority. (1990). Health Warnings on Cigarette and Tobacco Packs: Report on Research to Inform European Standardization; London, 1990.

25 Action on Smoking and Health. (1998).Tobacco Product Warnings: A Survey of Effectiveness; London, 1998.

26 Centre for Behavioural Research in Cancer, ACCV. Health Warnings and Contents Labelling on Tobacco Products,1992.

27 Strahan EJ, White K, Fong GT, Fabrigar LR,Zanna MP, Cameron R. (2002). Enhancing the Effectiveness of Tobacco Package Warning Labels:ASocial Psychological Perspective. Tobacco Control 2002; 11(3):183-90.

28 AGB Spectrum Research Ltd. (1987). Testing the Positions of Health Warnings on Cigarette Packages. Prepared for Health Promotion Programme, Department of Health, New Zealand, 1987.

29 Linthwaite P. (1985). Health warnings. Health Education Journal 1985; 44: 218-219.

30 Laugesen M. (1990). Optimal Wording and Pack Position for Strong Varied Disease Warnings on Cigarette Packs C in New Zealand. In: Proceedings of the Seventh World Conference in Tobacco or Health, 1990.

M 31 Nilsson T. (1991). Legibility of Tobacco Health Messages with Respect to Distance. A report to the Tobacco Y Products Division of the Health ProtectionBranch of Health and Welfare Canada, 1991.

CM 32 Prakit, V. (2008). Graphic Health Warning: How to Select the Right Picture. Paper presented at Regional Meeting

MY on Implementation of WHO-FCTC Article 11 (Tobacco Packaging and Labeling), 20-21 May 2008, Kuala Lumpur, Malaysia.

CY 33 Levie WH, Lentz R. (1982). Effects of Text Illustrations: A Review of Research. Educational Communication and

CMY Technology Journal 1982; 30: 195-232.

34 K Braun CC, Kline PB, Silver NC. (1995). The Influence of Colour on Warning Label Perceptions. International Journal of Industrial Ergonomics 1995; 15: 179-187.

35 Wogalter WS, Godfrey SS, Fontenelle GA, Desaulniers DR, Rothstein PR, Laughery KR. (1987). Effectiveness of Warnings. Human Factors 1987; 29: 599-612.

36 Sherman SJ, Cialdini RB, Schwartzman DF, Reynolds KD. (1985). Imagining Can Heighten or Lower the Perceived Likelihood of Contracting A Disease: The Mediating Effect of Ease of Imagery. Personality and Social Psychology Bulletin 1985; 11: 118-127.

37 Leventhal H. (1970). Findings and Theory in the Study of Fear Communications. In L. Berkowitz (Ed.), Advances in experimental social psychology (pp. 119-186)(Vol. 5). New York: Academic Press, 1970.

38 Liefeld JP. (1999). The Relative Importance of the Size, Content and Pictures on Cigarette Package Warning Messages. Department of Consumer Studies, University of Guelph, Prepared for Health Canada, 1999.

39 O'Hegarty M, Pederson LL, Nelson DE, Mowery P, Gable JM, Wortley P. (2006). Reactions of Young Adult Smokers to Warning Labels on Cigarette Packages. American Journal of Preventative Medicine 2006 Jun;30(6):467-73.

40 Adventist Development and Relief Agency (ADRA) and Department of Psychology Royal University of Phnom Penh. (2007). Survey report: Cambodia Public Opinion on Tobacco Control. Southeast Asia Tobacco Control Alliance, Bangkok, Thailand.

41 Center of Health Research, University of Indonesia. (2007). Indonesia’s Awareness on Health Warnings and Its Impact. Southeast Asia Tobacco Control Alliance, Bangkok, Thailand.

54 55.pdf 1 11/21/10 6:35 PM

42 Vanphanom S., Visanou H., Alongkon P. and Sysavanh P. (2008). Research on Health Warning Development in Vientiane, Lao PDR. Southeast Asia Tobacco Control Alliance, Bangkok, Thailand.

43 Framework Convention on Tobacco Control Alliance (FCAP). (2007).Cigarette Pack Test in the Philippines. Southeast Asia Tobacco Control Alliance, Bangkok,Thailand.

44 Vietnam standard and customer protection association (VINASTAS), Vietnam Public Heath Association (VPHA) and HealthBridge Vietnam (HBV). (2006). An Investigation on Custommer’s Opinions Regarding Health Warning on Cigarrette Pack. Unpublished report.

45 Environics Research Group. (2000).Testing New Health Warning Messages for Cigarette packages: A Summary of Three Phases of Focus Group Research: Final Report, Prepared for Health Canada, 2000.

46 Corporate Research Associates. (2005). Creative Concept Testing for Health Warning Messages. Prepared for Health Canada, 2005.

47 Clemenger BBDO. (2004). Marketing Inputs To Assist The Development of Health Warnings for Tobacco Packaging. Report to the Ministry of Health: Review of the Smoke-free Environments Regulations, 2004.

48 BRC Marketing & Social Research. (2004). Smoking Health Warnings Stage 1: The Effectiveness of Different (Pictorial) Health Warnings in Helping People Consider Their Smoking-Related Behavior. Prepared for the New Zealand Ministry of Health; May 2004.

49 Les Etudes de Marche Createc. (2006). Final Report: Qualitative Testing of Health Warnings Messages. Prepared for the Tobacco Control Programme Health Canada, June 2006.

50 Elliott & Shanahan (E&S) Research. (2003). Developmental Research for New Australian Health Warnings on Tobacco Products Stage 2. Prepared for: The Australian Population Health Division Department of Health and Ageing. Commonwealth of Australia, August 2003. C 51 M National Poison Center. (2007). Studying the Effect of Pictorial and Health Warning Labels on the Attitude of Children and Young Adults Towards Smoking in Malaysia. Focus group report submitted to Malaysian Ministry of Y Health.

CM 52 BRC Marketing & Social Research. (2004). Smoking Health Warnings Stage 2: Optimising Smoking Health MY Warnings-Text Graphics, Size, and Colour Tesing. Prepared for the New Zealand Ministry of Health, Aug 2004.

CY 53 Hammond D, Fong GT, McDonald P, Cameron R, Brown SK. (2003). Impact of the Graphic Canadian Warning CMY Labels on Adult Smoking Behavior. Tobacco Control 2003; 12: 391-395.

K 54 Hammond D, Fong GT, McDonald P, Brown, KS, Cameron R. (2004). Graphic Canadian Warning Labels and Adverse Outcomes: Evidence from Canadian Smokers. American Journal of Public Health 2004; 94 (8): 1442-45.

55 Thrasher JF, Hammond D, Fong GT, Arillo-Santillan, E. (2007). Smokers’ Reactions to Cigarette Package Warnings with Graphic Imagery and With Only Text: A Comparison between Mexico and Canada. Salud Pública de México 2007; 49 suppl 2: S233-40.

56 Hammond D, Parkinson C. (2009). The Impact of Cigarette Package Design on Perceptions of Risk. Journal of Public Health 2009; In Press.

57 White V, Webster B, Wakefield M. (2008). Do Graphic Health Warning Labels Have An Impact on Adolescents’ Smoking Related Beliefs and Behaviors? Addiction 2008;103(9):1562-71.

58 CRÉATEC and Market Studies.(2003). Effectiveness of Health Warning Messages on Cigarette Packages in Informing Less-literate Smokers, Final Report. Prepared for Communication Canada, Dec 2003.

59 Malouff J, Gabrilowitz D, Schutte N. (1992). Readibility of Health Warnings on Alcohol and Tobacco Products. American Journal of Public Health 1992; 82(3): 464.

60 Millar WJ. (1996). Reaching Smokers with Lower Educational Attainment. Health Reports / Statistics Canada, Canadian Centre for Health Information. 1996; 8: 11-9.

61 Siahpush M, McNeill A, Hammond D, Fong GT. (2006). Socioeconomic and Country Variations in Knowledge of Health Risks of Tobacco Smoking and Toxic Constituents of Smoke: Results from the 2002 International Tobacco Control Policy Evaluation Survey. Tobacco Control 2006; 15(Suppl III): iii65–iii70.

55 56.pdf 1 11/21/10 12:04 PM

62 The International Tobacco Control Policy Evaluation Project: ITC Thailand Summary, February 2009. 63 Environics Research Group. (1999). Canadian Adult and Youth Opinions on the Sizing of Health Warning Messages. Environics Research Group Limited, 1999.

64 Borland R, Hill, D. (1997).The Path to Australia's Tobacco Health Warnings. Addiction 1997; 92: 1151-1157.

65 Witte K, Allen M. (2000). A Meta-Analysis of Fear Appeals: Implications for Effective Public Health Campaigns. Health Education Behaviour 2000; 27:591–615.

66 UK Department of Health. (2007). Consultation on the Introduction of Picture Warnings on Tobacco Packs: Report on Consultation. August, 2007. Available at: http://www.dh.gov.uk/en/Consultations/Responsestoconsultations/DH_077960

67 Maizurah et.al. (2007). Evidence to Support Graphic Health Warning Labels on Cigarette Packs (Article 11). Report submitted to Malaysian Ministry of Health, September 17, 2007.

68 Health Canada. (2003). Toxics information on cigarette packaging: Results of a survey of smokers.Prepared by Environics Research Group; May 2003.

69 Guttman N, Peleg H. (2003). Public Preferences for an Attribution to Government or to Medical Research Versus Unattributed Messages in Cigarette Warning Labels in Israel. Health Communication 2003; 15(1): 1-25.

70 Henderson B. (2000). Wear Out: An Empirical Investigation of Advertising Wear-In and Wear-Out. Journal of Advertising Research 2000; 6: 95-100.

71 Bornstein RF. (1989). Exposure and Affect: Overview and Meta-Analysis of Research. Psychology Bulletin 1989; 106: 265-289.

72 C Hammond D, Fong GT, Borland R, Cummings KM, McNeill A, Driezen P. (2007). Text and Graphic Warnings on Cigarette Packages: Findings from the ITC Four Country Survey. American Journal of Preventative Medicine M 2007; 32 (3): 202–209.

Y 73 Health Canada. (1999). Health Warning Testing: Final Report. Prepared by Environics Research Group, 1999.

CM 74 Informa Market Research Co Ltd. (1999). Focus Group Research on New Health Warnings on Tobacco Packages. MY 1999.

CY 75 Hoffmann I, Hoffman D. (2004). The Changing Cigarette: Chemical Studies and Bioassays (Boyle P, Gray N, CMY Henningfield J, Sefrin J, Zatonski W. Eds). Oxford University Press. New York; 2004: p.53-92.

K 76 Pollay RW, Dewhirst T. (2001). Marketing Cigarettes with Low Machine Measured Yields. In: Smoking and Tobacco Control Monograph 13: Risks Associated with Smoking Cigarettes with Low Machine-Measured Yields of Tar and Nicotine. US Department of Health and Human Services. Bethesda, MD: US Department of Health and Human Services, Public Health Services, National Institutes of Health; National Cancer Institute, 2001:199–233.

77 Tobacco: End of the Tar Derby. Feb 15, 1960. Time. http://www.time.com/time/magazine/article/0,9171,871506,00.html (accessed Jul 30, 2007).

78 US Department of Health and Human Services. (2001). Risks Associated with Smoking Cigarettes with Low Machine Measured Yields of Tar and Nicotine. Bethesda, MD, USA: US Department of Health and Human Services, Public Health Services, National Institutes of Health; National Cancer Institute, 2001.

79 Benowitz NL. (1996). Biomarkers of Cigarette Smoking: The FTC Cigarette Test Method for Determining Tar, Nicotine, and Carbon Monoxide Yields of US Cigarettes. Report of the NCI Expert Committee. Smoking and Tobacco Control Monograph No. 7. US Department of Health and Human Services, National Institutes of Health, National Cancer Institute, NIH Publication No. 96–4028, 1996.

80 Hammond D, Collishaw N, Callard C.(2006).Tobacco Industry Research on Smoking Behavior and Product Design. The Lancet 2006; 367: 781–87.

81 O'Connor RJ, Kozlowski LT, Borland R, Hammond D, McNeill A. (2006). Relationship Between Constituent Labelling and Reporting of Tar Yields Among Smokers in Four Countries. Journal of Public Health 2006; 28(4):324-9.

82 Chapman S, Wilson D, Wakefield M. (1986). Smoker’s Understandings of Cigarette Yield Labels. The Medical Journal of Australia1986; 145: 376-379.

56 57.pdf 1 11/21/10 6:32 PM

83 Cohen JB.(1996). Consumer/smoker perceptions of Federal Trade Commission Tar Ratings. The FTC Cigarette Test Method for Determining Tar, Nicotine, and Carbon Monoxide Yields of U.S. Cigarettes. Report of the NCI Expert Committee. Smoking and Tobacco Control Monograph No. 7. U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute, NIH Publication No. 96-4028, 1996.

84 Gori GB. (1990). Consumer Perception of Cigarette Yields: Is The Message Relevant? Regul Toxicol Pharmacol 1990; 12: 64-68.

85 Devlin E, Eadie D, Angus K.`(2003). Low Tar Product Category. Prepared for NHS Health Scotland. Glasgow, UK: Centre for Tobacco Control Research, 2003. http://www.tobaccopapers.com/casestudies/index.htm#lowtarproduct

86 Hammond et al. (2007). Tobacco Control (ITC) Four Country Survey. Wave 5 Data; 2007.

87 Health Canada. (2003). Summary Report of Four Focus Groups in Toronto & Montreal on Awareness and Understanding on Toxic Emissions Information on Tobacco Packaging. March, 2003.

88 Dewar RE. (1999). Design and Evaluation of Public Information Symbols. In: Zwaga HJG, Boersma T, Hoonhout HCM, editors. Visual Information for Everyday Use: Design and Research Perspectives. London: Taylor and Francis. pp. 285–303.

89 Leonard SD, Otani H, Wogalter MS. (1999). Comprehension and Memory. In: Wogalter MS, DeJoy DM, Laughery KR, editors. Warnings and Risk Communication. London: Taylor and Francis. pp. 149–187.

90 Hara K, Mori M, Ishitake T, et al. (2007). Results of Recognition Tests on Japanese Subjects of the Labels Presently Used in Japan and the UN-GHS Labels. Journal of Occupational Health 2007;49(4):260-7.

91 Banda SF, Sichilongo K. (2006). Analysis of the Level of Comprehension of Chemical Hazard Labels:A Case for Zambia. Science of the Total Environment 2006; 363: 22–27.

92 C Sojourner RJ, Wogalter MS. (1998). The Influence of Pictorials on the Comprehension of and Recall of Pharmaceutical Safety and Warning Information. International Journal of Cognitive Ergonomics 1998; 2:93–106. M 93 Y Kalsher MJ, Wogalter MS, Racicot BM. (1996). Pharmaceutical Container Labels and Warnings: Preference and Perceived Readability of Alternative Designs and Pictorials. International Journal of Industrial Ergonomics CM 1996;18:83–90.

MY 94 Health Canada. (2007). Qualitative Testing o Toxic Emissions Statements. Prepared By Phoenix Strategic CY Perspectives for Health Canada; Nov 2007. Available at: www.tobaccolabels.ca/download/constitu/canada2007

CMY 95 Bansal-Travers M, Hammond D, Smith P, Cummings KM. The Impact of Cigarette Pack Design, Descriptors, and K Warning Labels on Risk Perception in The U.S. Submitted to the American Journal of Preventive Medicine. (Under review).

96 Freeman B, Chapman S, Rimmer M. (2008). The Case for the Plain Packaging of Tobacco Products. Addiction. 2008;103(4):580-90.

97 Pollay RW, Dewhirst T. (2002). The Dark Side of Marketing Seemingly "Light" Cigarettes:Successful Images and Failed Fact. Tobacco Control. 2002;11(Suppl 1):i18-31.

98 Shiffman S, Pillitteri JL, Burton SL, Rohay JM, Gitchell JG. (2001). Smokers’ Beliefs about “Light” and “Ultra Light” Cigarettes. Tobacco Control. 2001;10(Suppl I):i17-i23.

99 Ashley MJ, Cohen J, Ferrence R. (2001). 'Light' and 'Mild' Cigarettes: Who Smokes Them? Are They Being Misled? Canadian Journal of Public Health. 2001;92(6):407-11.

100 Etter JF, Kozlowski LT, Perneger TV. (2003). What Smokers Believe about Light and Ultralight Cigarettes. Preventative Medicine. 2003;36(1):92-8.

101 Gilpin EA, Emery S, White MM, Pierce JP. (2002). Does Tobacco Industry Marketing of 'Light' Cigarettes Give Smokers A Rationale for Postponing Quitting?Nicotine & Tobacco Research: official journal of the Society for Research on Nicotine and Tobacco. 2002;4:S147-55.

102 Weinstein ND (US Department of Health and Human Services, Public Health Services, National Institutes of Health). (2001). Public Understanding of Risk and Reasons for Smoking Low-Yield Products. In:Smoking and Tobacco Control Monograph 13: Risks Associated with Smoking Cigarettes with Low Machine-Measured Yields of Tar and Nicotine. Bethesda (MD): National Cancer Institute; 2001:193-98.

57 58.pdf 1 11/21/10 6:26 PM

103 Ling PM, Glanz SA. (2004). Tobacco Industry Research on Smoking Cessation: Recapturing Young Adults and Other Recent Quitters. J Gen Intern Ned. 2004;19(Pt 1):419-26.

104 Kropp RY, Halpern-Felsher BL. (2004). Adolescents' Beliefs about the Risks Involved in Smoking "Light" Cigarettes. Pediatrics 2004;114(4):445–51.

105 Hammond D, Arnott D, Dockrell M, Lee A, McNeill A. (2009). Cigarette Pack Design and Perceptions of Risk among UK Adults and Children. European Journal of Public Health 2009; In press.

106 King B, Borland R. (2005). What Was "Light" And "Mild" Is Now "Smooth" and "Fine": New Labeling Of Australian Cigarettes. Tobacco Control. 2005;14(3):214-5.

107 Hammond D. (2010). Cigarette Packaging and Beliefs Among Canadian Youth. 2010. Manuscript in preparation.

108 U.S. Surgeon General. (2001). Factors Influencing Tobacco Use Among Women. In: Surgeon General’s Report – Women and Smoking 2001: pp.453-536.

109 Doxey JR, Hammond D. (2010). Deadly In Pink: The Impact of Female-Oriented Cigarette Packaging on Brand Appeal, Beliefs about Smoking, and Risk Perceptions among Young Women.Paper presented at the Society for Research on Nicotine and Tobacco, 26 Feb 2010, Baltimore, MD.

110 Carpenter CM, Wayne GF, Connolly GN. (2005). Designing Cigarettes for Women: New Findings from the Tobacco Industry Documents.Addiction 2005; 100:837-851.

111 Klesges RC, Elliott VE, Robinson LA. (1997). Chronic Dieting and the Belief That Smoking Controls Body Weight In A Biracial, Population-Based Adolescent Sample. Tobacco Control 1997; 6: 89-94.

112 Kaufman AR, Auguston EM. (2008). Predictors of Regular Cigarette Smoking Among Adolescent Females: Does Body Image Matter? Nicotine & Tobacco Research 2008; 8:1301-1309.

C 113 Honjo K, Siegel M. (2003).Perceived Importance of Being Thin and Smoking Initiation Among Young Girls. M Tobacco Control 2003; 12: 289-295.

Y 114 White MA, McKee SA, O’Malley SS. Smoke and mirrors: Magnified beliefs that cigarette smoking suppresses

CM weight. Addictive Behaviors 2007; 32: 2200-2210.

MY 115 Hammond D, Doxey JR, Bansal-Travers M. (2010). The Impact of Female-Oriented Tobacco Packaging; February

CY 2010. (Manuscript in preparation.)

116 CMY Consumer Understanding of ”Mild Seven” Brand Name and On-Pack Notations: Opinion Research in Malaysia,

K Korea, and Hong Kong. Prepared for the JT Group by Research/Strategy/Management, Inc. October 2007.

117 Philip Morris, Marketing New Products in a Restrictive Environment [Internet]. 1990 Jun. [cited 2001 Sept 3]. Bates No. 2044762173-2364. Available from: http://www.pmdocs.com/getallimg.asp?if=avpidx&DOCID=2044762173/2364

118 McBride C. (1987). A Summary of Brand Imagery Studies on Canadian Products. Imperial Tobacco Limited Research and Development Division [Internet]. 1987 Sept. [cited 2007 Feb 20]. Bates No. 570506735- from: 6787. Available http://legacy.library.ucsf.edu/tid/mdb51f00/pdf?search=%22a%20summary%20of%20brand%20imagery%20studie s%20on%20canadian%20products%22

119 Aubin H. (1989). Are 'Generic' Packs Cigarettes' Future? 08/e [Internet]. 1989 Nov. [cited 2008 May 15]. Bates range 202338359.Available from: http://bat.library.ucsf.edu//tid/per26a99

120 de Craen AJM, Roos PJ, de Vries AL, Kleijnen Jos.(1996). Effect of Colour of Drugs: Systematic Review of Perceived Effect of Drugs and of Their Effectiveness. BMJ. 1996;313:1624-1626.

121 Kozlowski LT, Dreschel NA, Stellman SD, Wilkenfeld J, Weiss EB, Goldberg ME.(2005). An Extremely Compensatible Cigarette by Design: Documentary Evidenceon Industry Awareness and Reactions to the Barclay Filter Design Cheating the Tar Testing System. Tobacco Control 2005; 14(1): 64-70.

122 Dunn WL, Johnston ME. (1996). Market Potential of A Health Cigarette. Jun 1966. Bates No. 1000338644/8653. http://tobaccodocuments.org/landman/1000338644-8671.html

123 Cunningham R, Kyle K. (1995). The Case for Plain Packaging. Tobacco Control. 1995;4:80-6.

58 59.pdf 1 6/7/11 7:18 AM

124 Goldberg ME, Liefeld J, Madill J, Vredenburg H. (1999). The Effect of Plain Packaging on Response to Health Warnings. American Journal of Public Health. 1999;89:1434-5.

125 Beede P, Lawson R. (1992). The Effect of Plain Packages on the Perception of Cigarette Health Warnings. Public Health 1992;106(4):315-22.

126 Goldberg ME, Kindra G, Lefebvre J, Liefeld J, Madill-Marshall J, Martohardjono N, et al. (1995). When Packages Can’t Speak: Possible Impact of Plain and Generic Packaging of Tobacco Products. Expert Panel Report. Ottawa (Canada): Health Canada; 1995.

127 Hammond D. (2009). Potentially Misleading Information and Plain Packaging: New Canadian Findings. World Conference on Tobacco Health; 2009 March 9; Mumbai, India.

128 DiFranza JR, Eddy JJ, Brown LF, et al. (1994). Tobacco Acquisition and Cigarette Brand Selection Among the Youth. Tobacco Control. 1994;3:334–8.

129 Cummings KM, Morley C, Horan J, et al. (2002). Marketing to America's Youth: Evidence from Corporate Documents. Tobacco Control. 2002;11(suppl I):i5–i17.

130 Chapman S. (2007). Australia: British American Tobacco "Addresses" Youth Smoking. Tobacco Control 2007;16:2-3.

131 Northrup, David, and Pollard, J. (1995). Plain Packaging of Cigarettes, Event Marketing to Advertise Smoking and Other Tobacco Issues: A Survey of Grade Seven and Grade Nine Ontario Students. Toronto: York University; 1995.

132 Rootman I, Flay B. (1995). A Study on Youth Smoking Plain Packaging, Health Warnings, Event Marketing, and Price Reductions Key Findings. Toronto: University of Toronto, Centre for Health Promotion; 1995.

133 Trachtenberg JA. (1987). Here's One Tough Cowboy. Forbes. 1987 Feb 9;139:108. C

134 M Wakefield MA, Germain D, Durkin SJ. (2008). How Does Increasingly Plainer Cigarette Packaging Influence Adult Smokers’ Perceptions about Brand Image? An Experimental Study. Tobacco Control 2008; 17:416-421. Y 135 CM Neuber D. (2009). New Shapes, New Feel for Cigarette Packs. Tobacco Journal 2009; July 9.

MY 136 U.S Surgeon General. (2001). Patterns of Tobacco Use among Women and Girls. In: Surgeon General’s Report -

CY Women and Smoking 2001: pp.19-176.

137 CMY Chapman S, Carter SM. (2003). "Avoid Health Warnings on All Tobacco Products for Just As Long As We Can": A History of Australian Tobacco Industry Efforts to Avoid, Delay and Dilute Health Warnings on Cigarettes. Tobacco K Control 2003; 12 Suppl 3:Iii13-22.

138 Alechnowicz K, Chapman S. (2004). The Philippine Tobacco Industry: "The Strongest Tobacco Lobby in Asia". Tobacco Control 2004;13 Suppl 2:ii71-8.

139 BAT (British-American Tobacco Company). (1995). 1995 Key Area Paper: Corporate Affairs. Web Page. Available at: http://www.library.ucsf.edu/tobacco/batco/html/7200/7265/otherpages/allpages.html

140 Winder C, Azzi R, Wagner D. (2000). The Development of the Globally Harmonized System (GHS) of Classification and Labelling of Hazardous Chemicals. Journal of Hazardous Materials 2000; 125(1-3): 29-44.

141 White V, Webster B, Wakefield M. (2008). Do Graphic Health Warning Labels Have An Impact on Adolescents’ Smoking Related Beliefs and Behaviors? Addiction 2008;103(9):1562-71.

142 Willemsen MC. (2005). The New EU Cigarette Health Warnings Benefit Smokers Who Want To Quit the Habit: Results from the Dutch Continuous Survey of Smoking Habits. European Journal of Public Health 2005; 15(4): 389- 92.

143 Canadian Cancer Society. (2001). Evaluation of New Warnings on Cigarette Packages. Prepared by: Environics, Focus Canada 2001-3; 2001.

144 Hill D. (1988). New Cigarette-Packet Warnings: Are They Getting Through? The Medical Journal of Australia 1988; 148: 478-480.

59 60.pdf 1 11/21/10 6:41 PM

145 Persbericht Defacto: 28% van jonge rokers rookt minder door de nieuwe waarschuwingen op verpakking, Den Haag 26 november 2002.

146 Borland R, Hill D. (1997). Initial Impact of the New Australian Tobacco Health Warnings on Knowledge and Beliefs. Tobacco Control 1997; 6: 317-325.

147 Koval JJ, Aubut JA, Pederson LL, O'Hegarty M, Chan SS. (2005). The Potential Effectiveness of Warning Labels on Cigarette Packages: The Perceptions of Young Adult Canadians. Canadian Journal of Public Health 2005; 96(5):353-6.

148 Cavalcante TM. Labelling and Packaging in Brazil. National Cancer Institute, Health Ministry of Brazil; World Health Organization. Available at: http://www.who.int/tobacco/training/success_stories/en/best_practices_brazil_labelling.pdf

149Channel News Asia. (2006). Smokers Heed Graphic Warnings on Cigarette Packs: HPB Singapore Health Promotion Board. Press Release. 16 May 2006. Available at: http://www.channelnewsasia.com/stories/singaporelocalnews/view/208614/1/.html

150 Willemsen MC, Simons C, Zeeman. G. (2002). Impact of the New EU Health Warnings on the Dutch Quit Line. Tobacco Control 2002; 11: 382.

151 Miller CL, Hill DJ, Quester PG, Hiller JE.(1999). Impact on the Australian Quitline of New Graphic Cigarette Pack Warnings Including the Quitline Number. Tobacco Control. 2009 Feb 11. [Epub ahead of print]

152 Thrasher JF, Rousu MC, Ocampo-Anaya R, Reynales-Shigematsu LM,Arillo-Santillán E, Hernández-Ávila M. (2006). Estimating the Impact of Graphic Warning Labels on Cigarette Packs: The Auction Method. Salud Publica Mex 2006;48 Suppl 1:S155-66.

153 Thrasher JF, Rousu MC, Anaya-Ocampo R, Reynales-Shigematsu LM,Arillo-Santillan E, Hernandez-Avila M. (2007). Estimating the Impact of Different Cigarette Package Warning Label Policies: The Auction Method. Addict C Behav 2007;32(12):2916-2925.

M 154 Ministry of Health Brunei. (2007). Tobacco (Labelling) Regulations, 2007. Y 155 CM Royal Government of Cambodia. (2009). Sub-Decree on Printing Health Warning on Cigarette Packages, Royal Government of Cambodia, No. 181 ANKR.BK. MY 156 CY Ministry of Health Republic of Indonesia. Peraturan Pemerintah (PP) 19/2003.

157 CMY Ministry of Health Laos. (2006). Health Warning Decree.

K 158 Ministry of Health Malaysia. Food Act 1983, Control of Tobacco Product (Amendment) Regulations 2008 . Malaysia.

159 The Union of Myanmar (2006). The State Peace and Development Council, The Control of Smoking and Consumption of Tobacco Product Law (The State Peace and Development Council Law No 5/2006) (The 8th Waxing Day of Kason, 1368 ME) (4 May, 2006).

160 Department of Health (12 May 2010). Administrative Order No. 2010-0013, Office of the Secretary, Republic of the Philippines.

161 Ministry of Health Singapore. (2003). Smoking (Control of Advertisements and Sale of Tobacco) (Labelling) Regulations 2003.

162 The Health System Research Institute of Thailand. (1992). Thailand’s Tobacco Control Laws: Tobacco Products Control Act B.E.2535 (1992).

163 Minister of Health Vietnam. (2007). Government decree No 119/2007 ND-CP.

60 ABOUT SEATCA

The Southeast Asia Tobacco Control Alliance (SEATCA) works closely with key partners in ASEAN member countries to generate local evidence through research programmes, to enhance local capacity through advocacy fellowships, and to be the catalyst in policy development through regional fora and in-country networking.

By adopting a regional policy advocacy mission, it has supported member countries to ratify and implement the WHO Framework Convention on Tobacco Control (FCTC). SEATCA has been in existence since 2001 to act as supportive base for government and non-government tobacco control workers and advocates in the SEA region, primarily to Thailand, Malaysia, Cambodia and Vietnam. Currently, the alliance has formally extended to three more countries of Indonesia, Lao PDR, and the Philippines.

SEATCA was awarded the WHO Western Pacific Regional Office’s 2004 World No Tobacco Day Award in recognition of its major contribution to tobacco control in the region. “SEATCA has emerged as a major catalyst for advances made in tobacco control in the South East Asia Region, especially with regard to policy and legislation.”

- Dr Shigeru Omi, Regional Director for the Western Pacific Regional Office at the presentation of 2004 World No Tobacco Day Awards.

M SEATCA Objectives

Y 1) To form a supportive base for government and non-government tobacco control workers

CM in their efforts to promote the implementation of effective evidencebased national tobacco

MY control measures.

CY 2) To encourage greater cooperation between tobacco control workers at national and

CMY regional levels and to act as a regional leader on issues which affect all countries in the region. K 3) To facilitate information transfer and the sharing of experience and knowledge, to organize capacity building exercises, and to coordinate national and regional initiatives in tobacco control work. 4) To strengthen national tobacco control movements and to bring mainland Southeast Asian issues into the international tobacco control arena.

SEATCA Activities 1) Building local evidence through Collaborative research programme which provides funding, capacity building training, mentorship and platform to disseminate research studies to policy makers. The products from this programme are local evidences and knowledge for policy development. 2) Capacity building which focuses on strengthening local capacity on policy development through programmes named ASEAN fellowship programme and national tobacco control working group. 3) Regional network for policy development through SEATCA regional forum which highly responds to in-country policy movement. SEATCA organizes two regional fora per year focusing on policy issues like tobacco tax, health warnings, best practice on advertising ban, etc.

61 “Working together to promote the implementation of effective evidence-based tobacco control measures in Southeast Asia”

CMY

K Southeast Asia Tobacco Control Alliance Thakolsuk Place, Room 2B, 115 Thoddamri Road, Dusit, Bangkok 10300, Thailand Email: [email protected]

www.seatca.org

ISBN 978-616-90022-3-9