And Type the TITLE of YOUR WORK in All Caps

ADDRESSING THE TOBACCO EPIDEMIC IN LOW AND MIDDLE INCOME

COUNTRIES: BEST PRACTICES THAT REDUCE THE IMPACT OF TOBACCO

ADVERTISING, PROMOTION AND SPONSORSHIP

LORNA MCLEOD ENGLISH

(Under the Direction of Joel Lee)

ABSTRACT

Tobacco use is leading cause of preventable death in the world. The World Health

Organization (WHO) projects that by 2030 tobacco use will kill over 8 million people annually.

Eighty percent of the world’s smokers now live in low and middle income countries (LMIC) compared to 20 percent in developed countries. A primary reason for increased smoking in these countries is the tobacco industry’s targeted and aggressive marketing of cigarettes; billions of dollars are spent annually on tobacco advertising, promotion and sponsorship (TAPS).

In 2003, the WHO negotiated the Framework Convention on Tobacco Control (FCTC) to prevent the death and disease associated with tobacco use. The FCTC treaty calls for countries to enact comprehensive policies that ban TAPS and inform their populations about dangers of tobacco use. The treaty is founded on proven interventions that countries can implement to protect their population from the epidemic. The objective of this research is to examine tobacco-related policies in LMIC to assess their impact on smoking behaviors. The first study reviewed the impact of TAPS exposure and anti-TAPS policies on students’ smoking behavior in African LMIC. The second study examined the impact of anti-TAPS policies and counter-tobacco messages on male smoking behavior in

Thailand and Turkey.

The findings suggest that there is an association between TAPS exposure and increased smoking and susceptibility in the youth studied. It was determined that strong anti-TAPS laws are associated with decreased student exposure to advertising and sponsorship, while weak anti-

TAPS laws had no impact on exposure level. Further, weak anti-TAPS policies were associated with increased smoking behavior while strong-anti-TAPS policies were suggestive of decrease smoking. Finally, the findings demonstrate that effective enforcement of strong anti-TAPS policies over time can result in improved tobacco control outcomes in middle-income countries where smoking rates are high and tobacco use ingrained in the culture.

These findings provide recommendations to improve the effectiveness of tobacco control policies in LMIC. The global effort to regulate tobacco marketing and warn populations about the dangers of smoking is a vital and effective component of tobacco control that must be adopted by LMIC governments.

INDEX WORDS: Tobacco use, Smoking, Tobacco advertising promotion sponsorship,

TAPS, Anti-tobacco advertising, Counter-tobacco, Tobacco policies,

FCTC, Tobacco Control, Youth smoking, Africa tobacco control, Turkey

tobacco control, Thailand tobacco control, Tobacco Industry

ADDRESSING THE TOBACCO EPIDEMIC IN LOW AND MIDDLE INCOME

COUNTRIES: BEST PRACTICES THAT REDUCE THE IMPACT OF TOBACCO

ADVERTISING, PROMOTION AND SPONSORSHIP

LORNA MCLEOD ENGLISH

BS, HUNTER COLLEGE, 1980

MS, LONG ISLAND UNIVERITY, 1987

A Dissertation Submitted to the Graduate Faculty of the University of Georgia in Partial

Fulfillment of the Requirements for the Degree

DOCTOR OF PUBLIC HEALTH

ATHENS, GEORGIA

2014

Lorna McLeod English

ADDRESSING THE TOBACCO EPIDEMIC IN LOW AND MIDDLE INCOME

COUNTRIES: BEST PRACTICES THAT REDUCE THE IMPACT OF TOBACCO

ADVERTISING, PROMOTION AND SPONSORSHIP

LORNA MCLEOD ENGLISH

Major Professor: Joel Lee

Committee: Neale Chumbler Jessica Muilenburg Jason Hsia Samira Asma

Electronic Version Approved:

Maureen Grasso Dean of the Graduate School The University of Georgia May 2014

DEDICATION

I dedicate this dissertation to my family: To my inspiring mother, Calpurnia McLeod, for instilling in me the importance of hard work and reaching for my goals; to my father, Syrenius

McLeod, for his abiding faith in me; to my husband, Clarett English, for unselfishly providing the support and space required to achieve this goal; to my lovely children, Matthew and

RaeChelle, who keep me energized and motivated; to my dear sister, Ava and her children, Iman and Jamar, my niece Ayanna and nephew Tafari, for their enthusiastic encouragement; and finally, to my Decatur church family for unceasing prayers on my behalf. To my wonderful extensive village of family and friends, I thank you sincerely – my success is due to your unwavering love and support – God bless you.

ACKNOWLEDGEMENTS

I wish to acknowledge the esteemed members of my Advisory Committee for generously sharing their time and expertise with me in the completion of this research study.

Special thanks to Dr. Joel Lee, my Major Professor, for the countless hours of review, reflection and revisions; also to Dr. Jason Hsia for the intense statistical tutoring sessions and sage advice; sincere thanks to Dr. Neale Chumbler, Dr. Jessica Muilenburg, and Dr. Samira Asma for agreeing to serve on my committee.

I would also like to acknowledge and thank my colleagues at the Centers for Disease

Control and Prevention for allowing me to conduct this research and for providing the required resources. Special thanks to Ann Malarcher, Candace Kirksey Jones, and Linda Andes for providing their expertise and assistance. In addition, I sincerely appreciate the Division’s administrative staff, particularly Earthlyn Graham, Giselle Terrell, and Marcella Lottie, for their continuous support and encouragement throughout this process.

Finally, beyond the love and support of my family, this would not have been possible without the constant, sustaining love and power of God. To God be the glory.

TABLE OF CONTENTS

Page

ACKNOWLEDGEMENTS ...... v

CHAPTER

1 INTRODUCTION ...... 1

1.0 Overview ...... 1

1.1 The Tobacco Epidemic ...... 1

1.2 The Framework Convention on Tobacco Control ...... 2

1.3 Tobacco Advertising, Promotion and Sponsorship/Counter Advertising ...... 4

1.4 Focus on Cigarette Smoking ...... 8

1.5 Purpose of Research ...... 8

1.6 Research Design...... 9

1.7 Country Backgrounds and Profiles ...... 14

1.8 Summary ...... 31

2 LITERATURE REVEIW ...... 33

2.0 Literature Review Part One...... 33

2.1 Literature Review Part Two ...... 54

3 THE IMPACT OF TOBACCO ADVERTISING, PROMOTION AND

SPONSORSHIP EXPOSURE ...... 71

3.0 Abstract ...... 72

3.1 Introduction ...... 74

3.2 Background ...... 77 vi

3.3 Country TAPS Policy and Tobacco Use ...... 79

3.4 Methods...... 82

3.5 Results ...... 86

3.6 Discussion ...... 101

3.7 References ...... 110

4 AN ASSESSMENT OF POLICIES THAT BAN TOBACCO ADVERTISING,

PROMOTION, AND SPONSORSHIP ...... 116

4.0 Abstract ...... 117

4.1Introduction ...... 119

4.2 Background ...... 123

4.3 Methods...... 131

4.4 Results ...... 134

4.5 Discussion ...... 140

4.6 Conclusion ...... 144

4.7 References ...... 148

5 CONCLUSION ...... 155

5.0 Overview ...... 155

5.1 Background ...... 155

5.2 Research Questions and Findings ...... 156

5.3 Recommendations ...... 160

5.4 Future Challenges for Global Tobacco Control in Low and Middle Income

Countries ...... 165

5.5 Future Research ...... 167

vii

5.6 Research Limitations ...... 169

5.7 Summary ...... 169

REFERENCES ...... 172

APPENDICES

A Tobacco Control Progress Measures: Thailand and Turkey ...... 182

B GYTS/GATS Questions, Measures, Recodes ...... 185

C Examples of TAPS in Africa ...... 188

D Example of POS Advertising in Thailand ...... 197

E Examples of Warning Labels in Thailand and Turkey ...... 198

viii

CHAPTER 1

INTRODUCTION

1.0 Overview

This chapter will review the epidemic of tobacco use that is now the leading cause of preventable death in the world and examine the tobacco industry’s marketing strategy that has globalized tobacco use spreading the epidemic to low and middle-income countries (LMIC).

Additionally, it will include an examination of the public health field’s response to this urgent problem and LMIC government’s efforts to safeguard their population’s health. Finally, the chapter will end with a discussion of the purpose of the study and research design.

1.1 The Tobacco Epidemic

Tobacco use is the leading cause of preventable death in the world. The World Health

Organization (WHO) reported that at least 1.3 billion people smoke – approximately one third of the world’s adult population, and another 200 million use other forms of tobacco (WHO, 2013).

By 2030 it is projected that tobacco use will kill over 8 million people per year; with 80 percent of these deaths occurring in low and middle-income countries (WHO, 2013). A considerable shift in global smoking trends has occurred over the past few decades. Eighty percent of the world’s smokers now live in developing countries compared to 20 percent in developed countries

(WHO, 2013). This represents a striking reversal of the epidemic as smoking has declined significantly in developed countries and is now increasing in low and middle income countries.

Globally 12 percent of deaths for adults over 30 years old were attributable to tobacco use in 2004; that is more than 5 million adult deaths directly linked to tobacco use (WHO, 2013).

Currently, the regions with the highest tobacco-related death rates are North and South America and Europe due to the fact that these populations have a much longer history of tobacco use.

However, based on the latent period between tobacco use initiation and related morbidity, the epidemic of tobacco-related disease and death in LMIC is expected to catch up the epidemic in more developed countries (WHO Report, 2013).

1.2 The Framework Convention on Tobacco Control

Given that the global tobacco epidemic continues to spread – primarily in LMIC, the

World Health Organization (WHO) under the auspices of the United Nations in 2003 negotiated the first ever health treaty in an effort to address the epidemic. In 2005, the WHO Framework

Convention on Tobacco Control (FCTC) was ratified with more than 150 Parties or cosigning countries. As of December 2013, 177 of 193 WHO Member States have ratified the binding

Treaty indicating a commitment to its evidence-based provisions designed to reduce the supply of and demand for tobacco in their country and thereby prevent tobacco-related death and disease

(WHO Framework Convention on Tobacco Control, 2013a).

Last year, 2013, marked the tenth anniversary of the FCTC’s adoption and while there has been noteworthy progress in countries around the world, significant challenges remain in the successful implementation of the Treaty’s provisions. The Framework Convention provides a model for effective global action to negate the toll of the tobacco epidemic. However, the

Treaty’s success will depend on how effectively countries implement its provisions and on the level of support provided to countries with the political will to apply them. An important first step is to examine how countries have be able to implement and enforce the FCTC policies; measure the impact of their actions on tobacco control; and then use the lessons learned to enhance tobacco control effectiveness in all countries.

1.2.1 FCTC Evidence-based Provisions

The goals of the Framework Convention on Tobacco Control fall under two core provisions: i) to reduce the demand for tobacco – contained within Articles 6-14 of the Treaty and ii) to reduce the supply of tobacco – within Articles 15-17. The evidence-based policies recommended to achieve these goals include the following:

I. Demand Reduction

1. Price and tax measures that increase cost of tobacco

2. Regulation of tobacco advertising, promotion, and sponsorship

3. Education, communication, and public awareness of tobacco dangers

4. Packaging and labeling of tobacco products to warn and protect public

5. Protection from exposure to tobacco smoke

6. Regulation of the contents of tobacco products

7. Provision of tobacco cessation aid for people who want to quit

II. Supply Reduction

1. Reduction of illicit trade in tobacco products

2. Prevention of sales to and by minors

3. Provision of support for economically viable alternatives to tobacco production

Source: WHO Framework Convention on Tobacco Control, 2003

1.2.2 MPOWER – Measures of FCTC Implementation

Based on the measures of the FCTC Treaty, the WHO developed a package of tobacco prevention policies and interventions to be adopted by member countries’ national tobacco control programs. The package is known by the acronym MPOWER and is a convenient way for

policy makers and public health advocates to translate the provisions of the Treaty into practice and measure implementation progress.

M Monitor tobacco use through systematic surveys designed assess tobacco prevention policies and evaluate their impact P Protect people from tobacco smoke  completely smoke- free environment in all indoor public spaces and workplaces O Offer help to quit tobacco use  accessible services to manage tobacco dependence clinically Warn about the dangers of tobacco  high levels of W awareness of the health risks of tobacco use across the population E Enforce bans on tobacco advertising, promotion and sponsorship (TAPS)  complete absence of TAPS. R Raise taxes on tobacco products  progressively less affordable tobacco products

Figure 1.1: MPOWER Measures Source: WHO Report, 2008

According to the WHO 2013 Report, over 2,3 billion people living in 92 countries – one third of the global population – are covered by at least one MPOWER measure at the highest level of achievement. This is a notable accomplishment in just over a decade since the FCTC was adopted. Most of the progress in establishing MPOWER measures has been reported in low and middle-income countries.

1.3 Tobacco Advertising, Promotion and Sponsorship and Counter Tobacco Advertising

Tobacco advertising, promotion and sponsorship (TAPS) fall under two general approaches – direct and indirect strategies employed by tobacco industry with the aim, effect, or likely effect of promoting a tobacco product or tobacco use (WHO Framework Convention on

Tobacco Control, 2013c). Counter advertising, also called anti-tobacco advertising, is a strategy used by governments and health advocates to counter or diminish the impact of TAPS. Anti-

tobacco advertising messages and campaigns are designed to educate the public about the danger of tobacco use.

1.3.1 TAPS Definitions

The following definitions taken from the FCTC Treaty related to tobacco advertising, promotion and sponsorships are used throughout this document. It is understood that other disciplines may define these terms differently.

Tobacco advertising and promotion: any form of commercial communications, recommendation or action with aim, effect or likely effect of promoting a tobacco product or tobacco use either directly or indirectly.

Sponsorship: any form of contribution to any event, activity, or individual with the aim, effect or likely effect of promoting a tobacco product or tobacco use either directly or indirectly.

Direct and Indirect TAPS strategies: Direct TAPS strategies include use of traditional media channels such as print, radio or television to promote tobacco products; indirect strategies involve the use of non-traditional promotions such as displays at the points of sale, industry sponsorship of events or community initiatives, frequent price discounts that are broadly promoted and brand stretching or use of the industry name for non- tobacco products.

Comprehensive TAPS ban: legislation that requires a comprehensive ban on all tobacco advertising, promotion and sponsorship that applies to all forms of commercial communications, recommendations or action and all forms of contribution to any event, activity or individual with the aim, effect or likely effect of promoting a tobacco product or tobacco use either directly or indirectly. In addition the legislation addresses all persons or entities involved in the production, placement, and/or dissemination of TAPS.

Enforcement of TAPS ban: legislation that monitors compliance with the policies and applies effective, proportionate and dissuasive penalties (including fines, corrective advertising remedies and license suspension and cancellation) for infractions. Source: WHO Framework Convention on Tobacco Control, 2003

1.3.2 Impact of TAPS and Anti-TAPS Policies

Studies show that TAPS are extremely effective strategies for achieving the industry’s goals of getting people to start smoking or retaining loyal customers (WHO Report, 2013). In

addition to increasing the likelihood of smoking initiation, TAPS increases the social acceptability of tobacco use and weakens efforts to provide health education about the dangers of tobacco use. Cigarettes are among the most heavily advertised product, it is projected that tens of billions of dollars are spent on TAPS globally (WHO Report, 2013). Worldwide 78 percent of students aged 13-15 report being exposed regularly to some form of TAPS (WHO Report, 2013).

One study estimated that one third of youth experimentation with tobacco occurs as a result of

TAPS (WHO Report, 2013).

This issue is addressed by FCTC Article 13 wherein countries are called to avoid the effect of tobacco advertising, promotion and sponsorship by enacting comprehensive bans on direct and indirect TAPS. Effective policies that totally prohibit TAPS are among the most powerful tools that countries can implement to protect their population from the danger of tobacco. A comprehensive ban on all tobacco advertising, promotion and sponsorship could decrease tobacco consumption by an average of about 7 percent, with some countries experiencing a decline in consumption of up to 16 percent (WHO Report, 2013). However, as of

2012 only 24 countries among the 177 FCTC signatories have completely banned all forms of tobacco advertising, promotion and sponsorship – this represents only 10 percent of the world’s population (WHO Report, 2013). More than 100 countries have laws that restrict tobacco advertising, however, they need to be strengthened or modified to address all forms of TAPS.

There are 67 countries that have minimal or restrictions at all on tobacco advertising, promotion and sponsorship (WHO Report, 2013).

This research study will focus on the impact of tobacco advertising, promotion and sponsorship in low and middle-income countries along with policies or strategies used to regulate the marketing of tobacco. The tobacco industry spends tens of billions of dollars

worldwide each year on tobacco advertising, promotion and sponsorship and is effective in reaching their target population. It is well documented through studies conducted in developed countries that exposure to TAPS increase tobacco use, particularly among youth. However, very few studies have focused on the effect of TAPS exposure and anti-TAPS polies in LMIC.

1.3.3 Impact of Counter Tobacco Advertising

Counter tobacco advertising is an effective tool used to combat the impact of TAPS.

These typically involved the use of mass media campaigns to educate the population about tobacco-related health hazards and as public awareness increases social norms change which leads to reduced tobacco use. “Hard-hitting anti-tobacco mass media campaigns increase awareness of the harms of tobacco use, reduce tobacco use, increase quit attempts and reduce second-hand smoke exposures” (WHO Report, 2013). Studies show that although they are expensive to create and maintain mass-media campaigns are very effective in rapidly reaching large populations (WHO Report, 2013).

Article 12 of the FCTC addresses the issue of warning the public about the consequences of tobacco use. It calls for countries to “promote and strengthen public awareness of tobacco control issues, using all available communication tools, as appropriate” (WHO Framework

Convention on Tobacco Control, 2013b). According to the WHO 2013 Report, over half of the world’s population lives in countries where at least one anti-tobacco media campaign has been run within the past two year. While this is encouraging, it is also apparent that, counter- advertising spending by governments and public health advocates pale in comparison to the billions of dollars spent by the tobacco industry on TAPS. This study will also examine how middle-income countries have used counter-advertising or anti-tobacco messages to reduce tobacco use.

1.4 Focus on Cigarette Smoking

This research will focus on tobacco use in the form of cigarette smoking. Manufactured cigarettes are the most commonly consumed tobacco product and accounts for 96 percent of total worldwide sales. In 2009, 5.9 trillion cigarettes were consumed which represented a 12 percent increase in cigarette consumption over the past decade (Eriksen, Mackay & Ross, 2012).

Cigarette consumption dropped in Western Europe by 26 percent between 1990 and 2009 but increased in the Middle East and Africa by 57 percent during the same period (Eriksen, et. al,

2012). Cigarettes are one of the most heavily advertised commercial products in the world.

1.5 Purpose of Research

The objective of this research study is to examine the impact of tobacco advertising, promotion and sponsorship in low and middle income countries that fall into two primary categories – pre-epidemic and epidemic stages. The first group of countries (African countries) has recently been targeted for increased sales by the industry; with smoking rates that fall below

25 percent they are not yet addressing a full blown tobacco-related epidemic. The second group of countries (Thailand and Turkey) have attempted to reverse the tobacco epidemic for over a decade, smoking rates are high – particularly in males (over 40 percent), and these countries have implemented tobacco control policies that ban TAPS and use counter advertising or anti- tobacco messages to inform the public about the health hazards of smoking. This study will analyze tobacco-related data from these countries’ populations collected over time to determine the impact of TAPS policies and anti-tobacco messages on smoking behaviors over time. The outcome of this research will determine the best practices and policies that may be used to avert or reverse the tobacco epidemic in LMIC.

1.6 Research Design

1.6.1 Manuscript One

This paper will examine the impact of tobacco advertising, promotion and sponsorship

(TAPS) exposure and TAPS policy on tobacco behavior and susceptibility in students in low and middle income African countries. The expectation is that increased TAPS policy strength and compliance should result in decreased smoking prevalence and lower susceptibility to smoking over time. Conversely, weak TAPS policies or compliance should result in no change or an increase in smoking and susceptibility over time. The research plan is to analyze Global Youth

Tobacco Survey data from students in six countries collected over two or more data rounds to answer the research questions. i) Research questions

1. Is there an association between tobacco use and TAPS exposure?

H0: P1= P2

Ha: P1> P2

Where P1 is prevalence of tobacco use (dependent variable) in those exposed to TAPS

(independent variable) and P2 is the prevalence of tobacco use in those not exposed to TAPS.

2. Is there an association between tobacco susceptibility and TAPS exposure?

H0: P1= P2

Ha: P1> P2

Where P1 is level of susceptibility (dependent variable) of tobacco use in those exposed to

TAPS (independent variable) and P2 is the susceptibility to tobacco use in those not exposed

to TAPS.

3. Are there changes in TAPS exposure over time, by TAPS policy: none, weak anti-TAPS

laws, strong anti-TAPS laws? (see Table 1.2)

H0: P1 = P2

Ha: Not all Pi are equal

Where Pi is TAPS exposure at data collection periods before and after the law i ( i = 1, 2)

4. Are there changes in tobacco-related behavior and susceptibility over time, by TAPS policy:

none, weak anti-TAPS laws, strong anti-TAPS laws? (see Table 1.2)

H0: P1 = P2

Ha: Not all Pi are equal

Where Pi is TAPS exposure at data collection periods before and after the law i ( i = 1, 2) ii) Country Selection

Countries included in the analysis have the following characteristics:

-Low or middle-income (based on the United Nations criteria)

- Low prevalence of tobacco use (≤ 20 percent overall prevalence)

- Anglophone

- Completed at least two rounds of the Global Youth Tobacco Survey (GYTS)

- Represent one of three levels of TAPS policy adoption; i.e. none, weak, or strong policies

with varying degrees of policy enforcement and compliance. See Table 1.1 for country policy

categories. iii) Research Outcome

The outcome of this research may be used to assist in implementing effective tobacco

control policies specifically in African countries or other LMICs. Implementation and

enforcement of these policies are extremely important in developing countries where the

Table 1.1: Countries by TAPS Policy Category TAPS Policy Category Country GYTS Survey FCTC Anti-TAPS Rounds Ratified Law passed Nigeria ‘00, ‘08 2005 _ No Policy/No Compliance No national TAPS regulation Uganda ‘02, ‘07 2007 _

Botswana ‘01, ‘08 2005 1999/2004* Weak Policy/Weak Compliance Partial TAPS ban WHO compliance score = 3-7 Tanzania ‘03, ‘08 2007 2003

Kenya** ‘01, ‘07 2004 2007 Strong Policy/Strong Compliance Comprehensive TAPS ban Seychelles ‘02, ‘07 2003 1998/2009*

WHO compliance score = 8-10 South Africa ‘99, ‘02, ’07, ‘11 2005 1999 * Law amended **Kenya not included in data analyses due to the timing of TAPS law and GYTS data collection

prevalence of tobacco use is still relatively low and it is still possible to avert an epidemic and prevent tobacco related diseases and death.

1.6.2 Manuscript Two

This research paper will examine the impact of tobacco control policies, including tobacco advertising, sponsorship and promotion and counter-advertising on male smoking attitudes and behavior in Turkey and Thailand. Both countries have a disproportionately high prevalence of smoking in the male population and the governments of both these countries have responded by implementing strong tobacco control legislation. However, factors such as opposing policies (e.g. conflicting laws), policy evasion, or loopholes in the laws can affect enforcement and effectiveness of these laws. The hypothesis is that effective enforcement of strong policies should result in improved tobacco control outcomes over time. The research plan is to analyze two rounds of the Global Adult Tobacco Survey data for the Turkey and Thailand to answer the research questions.

i) Research questions

1. Are there changes in male smoking prevalence over time as tobacco control policies are

enforced, by country?

H0: P1 = P2

Ha: P1 > P2

Where Pi is prevalence in at data collection time period one and P2 is data collection time

period two. Change will be measured by the difference in prevalence between P1 and P2.

2. Are there changes in male smoking consumption over time as tobacco control policies are

enforced, by country?

H0: µ1 = µ2

Ha: µ1 > µ2

Where µ1 is the average number of cigarettes smoked at data collection time period one

and µ2 at data collection time period two.

3. Are there changes in male quit attempts over time as tobacco control policies are enforced,

by country?

H0: P1 = P2

Ha: P1< P2

Where Pi is prevalence of quit attempts at data collection time period one and P2 at data

collection time period two

4. Are there changes over time in male smoking behavior (i.e. type/brand of cigarettes smoked)

over time as tobacco control policies are enforced, by country

H0: P1 = P2

Ha: P1< P2

Where Pi is the prevalence of products used at data collection time period one and P2 at

data collection time period two

5. Are there changes in male exposure to TAPS and tobacco counter advertising over time, by

country?

H0: P1 = P2

Ha: P1 > P2

Where Pi is the prevalence of exposure at data collection time period one and P2 at data

collection time period two ii) Country Selection

Countries selected for this analysis are categorized as middle-income with male smoking rates that exceed 40 percent. The countries have completed two rounds of the Global Adult

Tobacco Survey (GATS) and have adopted comprehensive tobacco control policies that include regulation of tobacco advertising and promotion and sponsorship as well as implementation of counter-tobacco mass media campaigns. The countries of Turkey and Thailand both fit these criteria. iii) Research Outcome

The outcome of this research may be used to provide resources and technical assistance for low and middle-income countries with high smoking rates working to implement effective tobacco control policies that will reverse the tobacco epidemic and reduce related death and disease.

1.7 Country Backgrounds and Profiles

1.7.1 African Countries

Within the African Region (Sub-Saharan Africa) the tobacco industry has increased their marketing strategies in an effort to attract new customers with increasing disposable income.

Thirty-seven percent (17 of 46) African countries have enacted partial or full bans on direct

TAPS and have achieved a moderate or better level of compliance through enforcement of the laws (WHO Report, 2013). The seven African countries initially considered for inclusion in this study are categorized by the United Nations as either low or middle income; they also represent the various levels of strength for TAPS-related policies (see Figure 1.1). Two of these countries have no national laws that ban TAPS – Nigeria and Uganda; another two – Botswana and

Tanzania – have moderate laws with weak enforcement; finally three governments have enacted and enforced strong laws that ban TAPS – Kenya, Seychelles, and South Africa. Kenya, however, collected the second round of GYTS data in 2007 which was immediately after comprehensive anti-TAPS legislation was adopted – it was therefore assumed that inadequate time had lapsed to observe an effect of the Kenyan policies. As a result Kenya was not included in data analyses, therefore the remaining six countries were the focus of this research study (see

Table 1.2 for country tobacco profiles).

The following is a detailed description of the tobacco-related history and situation in each of the six African countries. i) Nigeria: No TAPS Policy

Nigeria is a middle income country of 162 million people. According to the Global Adult

Tobacco Survey conducted in 2012, 3.9 percent of the population currently smokes cigarettes –

7.3 percent of males and 0.4 percent of females (CDC, 2013a). On average each Nigerian

Table 1.2: African Countries’ Tobacco Profile Nigeria Uganda Botswana Tanzania Kenya◊ Seychelles South Africa National legislation banning No No Yes Yes Yes Yes Yes TAPS Date enacted ------1999/2004* 2003 2007 1998/2009* 1999 Compliance with policy ------Weak Weak Strong Strong Strong FCTC treaty signed/ratified 2004/2005 2004/2007 2003/2005 2004/2007 2004/2004 2003/2003 2003/005 Direct TAPS bans: No No Yes Yes Yes Yes Yes TV/radio/print/billboards/etc. Indirect TAPS bans: Free distribution/discounts//promotion No No No Yes Yes Yes Yes items /sponsored events/etc. National tobacco control program Yes Yes Yes No Yes Yes Yes Youth prevalence – (%) 2.6 – 6.2+ 4.8 14.3 1.7 - 3.6+ 8.2 21.5 12.7 (GYTS: ages 13-15 ) (2008) (2010) (2008) (2008) (2007) (2007) (2010) Adult prevalence** - M / F (%) 8 / 1 15 / 1 20 / 2 17 / 1 22 / 1 21 / 2 21 / 7

1999/2002/ GYTS survey data/years 2000/2008 2002/2010 2001/2008 2003/2008 2001/2007 2002/2007 2007/2010

Population 162 million 35 million 2 million 46 million 42 million .086 million 51 million (World Bank 2011) Income category Middle Low Middle Low Low Middle Middle ◊ Kenya not included in data analyses due to the timing of TAPS law and GYTS data collection * Legislation amended ** 2009 WHO estimate + Range of regional areas

smokes 116 cigarettes per capita (Eriksen et. al, 2012). The estimated annual death due to tobacco use is low at 2.3 per 100,000 in men (no estimates available for women) (Eriksen et. al,

2012). The average price per pack of cigarettes in equivalent US dollars was $1.43 in 2010 and excise taxes represent 15.9 percent of the price of each pack (Eriksen et. al, 2012). The affordability of cigarettes, referred to as the relative income price (RIP), is calculated as the percent of annual per capita income required to purchase 100 packets – the RIP was 9.66 percent

(Eriksen et. al, 2012).

According to the 2012 GATS findings, the average age of smoking initiation is16 years; therefore it probable that attitudes toward smoking are formed in earlier years. Forty-five percent of the Nigerian population is under 15 years of age (United Nations, 2013). Youth smoking rates among school children between 13 and 15 years old ranged between 2.6 and 6.2 percent depending on the region of the country (CDC, 2013b). Nigeria is among the countries with the highest proportion of children out of school worldwide. The United Nations Educational,

Scientific and Cultural Organization’s (UNESCO) 2013 report indicates that one of every five

Nigerian child was not attending school in 2010 (U.N., 2013).

Nigeria cultivates tobacco and produces cigarettes and other tobacco products. There was a 45 percent reduction in land area devoted to tobacco harvesting over the past decade from

37,000 hectares in 2000 to 20,358 and cigarette production decreased 40 percent to a low of

14,103 tons in 2009 (Eriksen et. al, 2012).

Nigeria signed the Framework Convention on Tobacco Control in 2004 and ratified it in

2005 at which time the treaty was entered into force or became binding. According to the 2011

WHO Report, Nigeria has developed national strategies, plans and programs that addresses tobacco control. There is a national agency for tobacco control with a staff of 58 full time

equivalents and a budget of $43,717 in US equivalent dollars (2009) (WHO Report, 2011).

Nigeria has enacted a national law that bans smoking indoors in certain public facilities, however, there is no national law enacted that bans direct tobacco advertising, promotion or sponsorship.

In 2009 a National Tobacco Control bill was introduced in the Nigerian Senate. After two years, the Senate passed the bill in March 2011 generating much excitement and hope for change in the political attitude toward tobacco control. However, the bill remains unsigned by the President despite numerous calls from tobacco control advocates for its ratification.

Industry forecasters claim that in 2011 the tobacco market registered the strongest value growth ever. According to Euromonitor International, the increase in urban population and westernization continue to contribute to a slow rise in smoking prevalence (2013). In 2011,

British American Tobacco (BAT) informed shareholders that “In Nigeria volumes were up and market share continued to grow” (Ogala, 2012). The company predicted this positive forecast based on a blanket “population growth and increasing disposable income.”

The Cross River States local government in Nigeria passed a law prohibiting tobacco advertising in the media in 2001, however, alternate marketing strategies such as colorfully branded retail kiosks, student parties, promotional events in bars and clubs, and free souvenirs, have largely circumvented any efforts to restrict tobacco marketing. The BAT Company has an ongoing strategic relationship with the Nigerian government and readily admits that it is a major player in defining the rules and set their own internal marketing standards. ii) Uganda: No TAPS Policy

Uganda is classified as a low income country with a population of 35 million people.

Based on the WHO 2009 estimate the prevalence of cigarette smoking is 15 percent for males

and 1.4 percent for females (WHO Report, 2011). Per capita cigarette consumption is relatively low at 24 and the annual estimated tobacco-related death rate for males is only 1.6/100,000 and

0.5/100,000 in females (Eriksen, et.al, 2012). The average price per pack of cigarettes in US equivalent dollars was $0.51 in 2009 and excise taxes were 29.3 percent of the price (Eriksen, et.al, 2012). The affordability of cigarettes based on the relative income price was comparatively low at 14.8 percent (Eriksen, et.al, 2012).

Youth smoking rates among school students aged 13 to 15 remain relatively low based on the most recent GYTS at 4.8 percent (CDC, 2013b). According to a Save the Children 2012 report, 18 percent of school aged Ugandan children are not enrolled in school and the drop-out rate averages 66 percent.

According to the InterPress News Services, Uganda has become a key tobacco producer for British American Tobacco six years after a regional headquarters hub was created there. Land use for tobacco cultivation increased slightly over the last decade, however, production decreased by 18 percent over the same period (Boase, 2012).

Uganda signed the FCTC in 2004; however the treaty was not ratified by the government until 2007. While Uganda has national strategies and plans to address tobacco, there is no national agency for tobacco control. In 2009 the national budget for tobacco control was the US equivalent of just over one thousand dollars (WHO Report, 2011). The Ugandan parliament passed a regulation that provides for smoke-free environments in health care facilities as well as educational and governmental offices. However, there is no law or policy that prohibits tobacco advertising, promotion and sponsorship.

Tobacco industry advertising is widespread. The primary company, British American

Tobacco, traditionally sponsors sports-related events; however, within the past decade has

received increasing criticism for its aggressive marketing tactics. Ugandan athletes spoke out publicly and called the sponsorships abusive of sports (Chapman, 2000 & Tobacco Control,

2000). Direct marketing is no longer as prominent as in the past; however, street party sponsorships and point of sale promotions are on the increase. iii) Botswana: Weak TAPS policy

Botswana is a middle income country with a population of 2 million people. Within the

African Region, the prevalence of cigarette smoking is relatively high in Botswana. Males smoke at a rate of 20.1 percent and females at a significantly lower rate of 1.5 percent (WHO Report,

2011). The cigarette consumption level per person is high at 336 and the estimated annual death rate related to tobacco use for males and females is 3.4/100,000 and 0.3/100,000 respectively.

(Eriksen et. al, 2012). The average price per pack of cigarettes is $2.08 in equivalent 2009 US dollars and of that 39 percent is for excise taxes (Ibid). The relative income price is only 3.48 percent of annual income required to purchase 100 packs. Botswana is not a tobacco producing country and relies on neighboring countries for the import of tobacco products.

Traditionally it is taboo for school-age children to be seen smoking in public. However, smoking rates among youth appears to be increasing. In 2008, GYTS data showed a prevalence of 14.3 percent among students between 13 and 15 years of age (CDC, 2013b). In Botswana education is compulsory until 15. In 2005 85 percent of primary school children were enrolled but only 55.9 percent of secondary school aged children were enrolled (U.N., 2013).

Botswana signed the FCTC in 2003 and ratified it in 2005. Much earlier in 1999 the government enacted the Control of Smoking Act which prohibited sale of tobacco to youth under

16 and regulated smoking and smoke-free environments. In 2004 the law was amended to include warning labels on cigarette packs and strengthen the marketing ban. Tobacco advertising

was banned on national TV and radio, local magazines and newspapers, billboards and outdoor spaces as well as point-of-sales. The Act further banned the appearance of product bans in TV shows or movies. However, indirect marketing such as free distribution, promotional discounts and sponsored community events are not affected by the current version of the legislation.

Botswana has developed specific national tobacco control objectives and a national agency with a staff of three who focus on implementing the program. However, it has been generally reported that enforcement of the existing Control of Smoking Act has been lenient and ineffective (Mbongwe, 2004, African Tobacco Resource Center, 2013). The industry continues to violate provisions of the law and use indirect marketing in the form of club and bar promotions, brand stretching which includes use of industry logos or colors designs on items that are given away, and event sponsorship. Tobacco control advocates and non-governmental organizations, such as the Anti-Tobacco Network, continue to appeal to the government for full implementation of the FCTC and more robust enforcement of the current laws to include monitoring and penalties for infractions. iv) Tanzania: Weak TAPS Policy

The United Republic of Tanzania is a low income country of 46 million people.

According to WHO, 2009 prevalence estimates of the rate of cigarette smoking in males is 17.4 percent and 1.2 percent for females (WHO Report, 2011). Per capita consumption of cigarettes is 132 (Eriksen et.al, 2012). The price of a pack of cigarettes in US equivalent dollars is $1.29 and only 10.9 percent is designated for excise taxes (Eriksen, et.al, 2012). The relative income price is 34.1 percent of annual income for 100 packs of cigarettes (Eriksen, et.al, 2012).

In Tanzania, it is compulsory for children over seven years to enroll in primary education.

In 2000 57 percent of children between 5 and 14 years were actually attending school (US Dept.

of Labor, 2012). Based on the most recent GYTS data, student rates of smoking are relatively low at 1.7 percent to 3.6 percent depending on the region of the country (CDC, 2013b).

Tobacco is an important crop for Tanzania, cultivation and export is a key goal of the government’s economic growth plan. Tobacco is farmed on 41,000 hectares of land, productions has increased 110 percent over the past decade to 55,400 tons which gives Tanzania a global ranking of 14th in tobacco production (Drope, 2011).

Tanzania signed the FCTC in 2004 and then ratified it in 2007. In 2003 the government enacted the Tobacco Products (Regulation) Act, 2003. The law’s objective is to reduce tobacco use and the resulting harm by “protecting persons under 18 and other non-smokers from inducements to use tobacco products.” The legislation bans direct advertising on national and international TV, radio, newspapers and magazines, outdoor spaces and the internet. No ban was placed on point-of-sale advertising. The law extends the ban to distribution of free cigarettes and product brand placement on TV or movies. Despite the intent of the law, it was widely reported that the tobacco industry continued to be very active, taking advantage of loopholes in the law and weak enforcement of it provisions (Tanzania Tobacco Control Forum, 2011). Strategies employed by tobacco companies include significant cash and equipment donations to grassroots projects, schools, farmers, female artists; sponsorships of government and police official’s programs. The industry continues to enjoy an ongoing working relationship with the government with strong support for protecting the tobacco farming and production industry. A number of non-governmental organizations work to educate the public and school students on the dangers of tobacco use. Tobacco control advocates continue to call for enforcement and strengthening of the existing Tobacco Products Act.

vi) Seychelles: Strong TAPS Policy

Seychelles is a middle income island nation of 86,000 people. Prevalence of cigarette smoking is relatively high at 21 percent for males and 2 percent for females (WHO Report,

2011). Per capita cigarette consumption is high at an average of 565 and the estimated deaths in

2004 due to tobacco for males and females were 7.3 and 2.4 per100,000 respectively (Eriksen et.al, 2012). The price per pack of cigarettes is relatively high at $5.43 (US equivalent) of which

67.6 percent is for excise taxes – also relatively high (Eriksen, et.al, 2012). The price of 100 packs is equivalent to only 5.74 percent of the annual per capita income (Eriksen, et.al, 2012).

Based on the most recent GYTS, the prevalence of smoking among 13 – 15 year old students in Seychelles is among the highest in the African region at 21.5 percent (CDC, 2013b).

Data was not available on the percentage of youth enrolled in school. However, smoking is clearly a significant public health problem in Seychelles. Seychelles does not grow or produce tobacco and imports tobacco products through British American Tobacco Company.

Seychelles signed and ratified the FCTC early in 2003 and was the first nation in the

African region to do so. Since the 1980s an active tobacco control program has provided health education to the public on the dangers of tobacco use and worked to prohibit advertising and increase tobacco taxes. The Seychelles Tobacco Control Act was prepared by a national multi- sectorial committee in 2000; however it was not adopted by the National Assembly until 2009 – albeit unanimously (Viswanathan, 2011). Passage of the Act required several years to overcome intense resistance by the hospitality sector to the total ban on public smoking. As a vacation destination, the island’s economy relies heavily on tourism thus the hospitality industry felt that the ban would hurt business.

The Tobacco Control Act strengthened the existing policies and improved compliance with the ban on tobacco advertising, promotion and sponsorship. A National Tobacco Control

Board was created to address offenses and penalties for violations of the law. Seychelles has a national agency for tobacco control with one full time equivalent and an annual budget of

$20,000 (WHO Report, 2011). vii) South Africa: Strong TAPS Policy

South Africa is a middle income country of 51 million people. The 2009 prevalence of cigarette smoking was relatively high for males and females at 21.2 percent and 7.2 percent respectively (WHO Report, 2011). The female rate represents the highest rate for females in the region. Per capita consumption of cigarettes is relatively high for the region at 459 (Eriksen et. al, 2012). The estimated annual death rate due to tobacco use is also high at 11 per 100,000 for males and 2.4 for females (Ibid). It would then follow that youth rates of smoking would also be relatively high. For 13 to 15 year old students the prevalence of cigarette smoking was 13.6 percent in 2011 (CDC, 2013b). The price per pack of cigarettes is higher than average for the region at $4.18 with 40.7 percent of the price is allocated for excise taxes (Eriksen, et. al, 2012).

The relative income price of 100 packs is 4.87 percent of annual per capita income. Tobacco cultivation has fallen in recent years by 15 percent however tobacco manufacturing continues to be quite robust with BAT controlling 90 percent of the cigarette market (Drope, 2011).

South Africa signed the FCTC in 2003 and ratified it in 2005. The government has a national tobacco control strategy, plans and programs. The national agency that focuses on tobacco control has four full time equivalents with an annual budget of $302,618 in USD. (WHO

Report, 2011)

South Africa has achieved a remarkable and significant decrease in tobacco use due to a strong public health advocacy community and effective tobacco control initiatives put in place by the government. Prevalence remains among the highest in the Region. Four major tobacco control laws have been enacted since 1993. Spending on direct tobacco advertising by the tobacco industry had increased five-fold from 45 million rand in 1987 to R250 million in 1997.

Tobacco company sponsorships for sports, arts, and cultural organizations amounted to R49 million in 1997 – in total R477 million was spent on advertising, promotions and sponsorships that year (Saloojee, 2006).

In 1993 the Tobacco Act allowed the Ministry of Health to prescribe health warning on advertisements. Eventually in 1999 the amended Tobacco Act banned all tobacco advertising and sponsorships; restricted point-of-sales advertising to listing availability and price only. Further amendments later restricted the size of point-of-sale notices and phased out existing contractual sponsorships and advertising obligations. The most recent amendment in 2012 banned virtual advertising of tobacco products. South Africa is recognized as having one of the world’s most robust and comprehensive laws that control tobacco manufacturing, export, smoking, marketing, and taxation. Taxes increased the price of cigarettes by 157 percent between 1992 and 2008 and tobacco consumption decreased by 35 percent (WHO Report, 2011). The Ministry of Health was given the authority to make regulations, enforce policies and penalties in implementing the law.

The industry made several attempts to delay passage of these amendments and get them struck down. Law suits were filed that took years to resolve. The most recent appeal by BAT argued that the legislation violated their constitutional right to communicate with their customers; however it was denied by the Supreme Court of Appeals of South Africa in June

2012. Industry forecasters predict a sharp downturn in tobacco value in South Africa due to “a stricter operating environment.” (Euromonitor International, 2013).

Table 1.3 Cigarette Statistics by Country Male Smoking Price per Pack Affordability Excise Tax Per Capita Prevalence (%) (USD) Index (%)* per Pack (%) Consumption

Nigeria 7.3 1.43 9.66 15.9 116 Middle income Uganda 15.0 0.51 14.8 29.3 24 Low income Botswana 20.1 2.08 3.48 39.1 336 Middle income

Tanzania 17.4 1.29 34.09 10.9 132 Low income Kenya 22.5 3.01 28.1 50.0 144 Low income Seychelles 21.1 5.43 5.74 67.6 565 Middle income South Africa 21.2 4.18 4.87 40.7 459 Middle income * Relative Income Price (percent of annual per capita income required to purchase 100 packs)

Sources: WHO Report, 2011; Eriksen et.al, 2012

1.7.2 Country Profiles: Thailand and Turkey i) Thailand

Thailand is a middle income country of 67.1 million people located in the WHO

Southeast Asian Region. According to the 2011 GATS, 26.9 percent of the population smoked cigarettes – 46.4 percent of males and 7.6 percent of females (CDC, 2013a). The average per capita consumption of cigarettes among the Thai population is 560 and the 2004 estimated rates of death due to tobacco use was 16 per 100,000 men and 10.7 per 100,000 women (Eriksen et. al,

2012). The average price per pack of cigarettes in equivalent US dollars was $2.56 in 2010 and excise taxes represent 62 percent of the price of each pack (Ibid). The affordability of cigarettes

or the relative income price is 3.67 percent of annual per capita income required to purchase 100 packets (Eriksen et. al, 2012).

Approximately 20 percent of the Thai population is under the age of 15 (U.N., 2013).

According to the most recent GYTS (2009), the students smoking rate for ages 13 to 15 years is

11.7 percent - 17.4 percent for boys and 4.9 percent for girls (CDC, 2013b). This reflects a 2.6 fold difference between boys and girls.

Thailand is a tobacco producer. In 2009, 72,000 tons of tobacco was produced which was a slight reduction since 2000 (Eriksen et. al, 2012). Cigarette production has been managed by the government since 1939 through the Thailand Tobacco Monopoly. In 1991 foreign imports were allowed into the country and by 2007 imported cigarettes were almost 25 percent of the market - up from 2.7 percent in 1992 (Tobacco Control Research & Knowledge Management

Center, 2008). In response to a decrease in market share the Monopoly approved the launch of two rather inexpensive brands of Thai cigarettes that targeted low-income smokers. A significant component of tobacco production takes place at the local level operated by individual farmers and small businesses. This loose tobacco is used for roll-your-own cigarettes. About half of cigarette smokers use hand rolled also known as ‘roll-your-own’ and the other half smoke manufactured cigarettes. The prevalence of roll-your-own cigarettes is highest in rural areas and among lower socioeconomic status and less educated groups (Ministry of Public Health

Thailand, 2012).

Thailand signed the WHO FCTC in 2004 and ratified the treaty in March 2005. Thailand has had a significant history of tobacco control activities. A national tobacco control program has been in place since 1986. In 1992, the Thai government enacted two major pieces of tobacco control legislation: 1) the Non-smoker’s Health Protection Act which designated totally smoke-

free public places versus partially smoke free places; and 2) the Tobacco Products Control Acts which banned all types of tobacco advertising and promotion – sponsorship was not addressed.

The law also banned sales of tobacco to those less than 18 years of age and required large, graphic health warnings to be printed in color that depicted the danger and health outcomes of tobacco use. Most recently, amendments to the law increased the number of totally smoke-free public places. Cigarette packs graphic warnings included information on how to obtain help to quit smoking. Finally, the government also improved the enforcement strategy for addressing violations of the law through monthly monitoring by law enforcers and tobacco control networks.

The economic industry forecasters noted that in 2011, cigarettes decreased in volume sales and growth in tobacco smoking slowed down. However, cigars posted the strongest volume growth ever in 2011. The increased price and extensive anti-smoking campaigns conducted by the government and health organizations are ‘blamed’ for the slowdown. The forecasters project that a “tough situation for tobacco consumption is expected over the forecast period. Smoking is becoming an increasingly antisocial activity, and no longer appeals to the younger generation in terms of fashion. As a result, it is becoming more difficult to cultivate new smokers. In addition, people are becoming more health-conscious due to mandatory health checks.”(Euromonitor

International, 2012).

Thailand has been cited for many of its strict tobacco control provisions, however, the rate of smoking remains high in males and has not shown a significant decline over the past several years. An examination of the impact of tobacco control policies in this nation will provide important information to improve their effectiveness in Thailand and in other middle income countries.

ii) Turkey

Turkey is a middle income country of 75.6 million people located in the WHO European

Union Region. According to the 2012 Global Adult Tobacco Survey, 27.1 percent of the population smoked cigarettes – 41.9 percent of males and 13.1 percent of females (CDC, 2013a).

The average per capita consumption of cigarettes for the Turkish population is 1399 – this is among the highest rates in the world (Eriksen et. al, 2012). Turkey is among the top 10 tobacco- consuming countries and uses 14 percent of the tobacco products consumed in the WHO

European Region (Ministry of Health Turkey, 2010). The estimated 2004 death rate due to tobacco was 37.6 per 100,000 men and 5.8 per 100,000 women (Eriksen et. al, 2012). The average price per pack of cigarettes in equivalent US dollars was $4.38 in 2010 and excise taxes represented 63 percent of the price of each pack (Eriksen et. al, 2012). The affordability of cigarettes or the relative income price is 2.88 percent of annual per capita income required to purchase 100 packets (Eriksen et. al, 2012).

Over 26.2 percent of the Turkish population is under the age of 15 (U.N., 2013).

According to the most recent GYTS (2005), the students smoking rate for ages 13 to 15 years is

23 percent - 22.1 percent for boys and 16.6 for girls. These adolescent rates for gender are much closer than rates for adult male and females (CDC, 2013b).

Turkey is a tobacco producer. In 2009, 85,000 tons of tobacco was produced, however, this reflects a reduction of 57.6 percent since 2000 (Eriksen et. al, 2012). The main method of selling cigarettes in Turkey includes small grocers, newsagent kiosks and street vendors

(Euromonitor, 2013).

Turkey signed the FCTC in 2004 and ratified the treaty just 4 months later in March

2005. Turkey has been a model state for aggressive tobacco control legislation. Prior to

ratification, Turkey privatized the tobacco government monopoly and then developed the

Tobacco and Alcohol Market Regulatory Authority. The Authority’s mission was to “regulate tobacco and alcoholic beverages, taking into account the economics of the country, as well as public health concerns, and also protection of social values of the community (Ministry of Health

Turkey, 2010). In 2006 a national tobacco control unit within the Ministry of Health was created and charged with implementing the national tobacco control program and plan. Eventually the unit was promoted to the Directorate level within the Ministry with a budget of $1.3 million (US equivalent) and 8 full time equivalent employees (Bilir, Ozcebe, Erguder & Mauer-Stender,

2012). In 2008 the government amended the1996 Law on Prevention and Control of Hazards of

Tobacco Products. The amendment prohibited public smoking; tobacco advertising, promotion and sponsorship with penalties for violations; it regulated tobacco product packaging and labeling; and provided public education campaigns. The Ministry of Health was authorized to publish a number of legislative letters that instructed local governments on their obligations to comply with and enforce the law. The 2008 law significantly expanded the smoke-free provision to include all public places including hospitality sector. It met with fierce resistance from the hospitality industry; however, with the 18-month phase-in period; pressure from NGOs and tobacco control advocates; increasing public support; and an unfavorable ruling from the

Constitutional Court, the smoke-free provision was accepted and enforced.

Another provision of the amended law increased tobacco products taxation so that the total tax on products comprised 78 percent of the retail price. Cigarette prices more than doubled over the last decade (Bilir et. al, 2012). Although the price per pack in Turkey as compared to most of the continent of Europe is still somewhat low ($4.5 USD equivalent).

The 1996 law banned advertising and promotion of tobacco products, but did not address sponsorship. The 2008 amendment strengthened the existing law and included a ban on sponsorship. It went even further by banning the sale of less than a full pack or individual sticks of cigarettes. Electronic sales, such as internet and telephone shopping were banned. Points-of- sale advertising were restricted so that they could not be seen from outside the place of business.

Finally, no non-tobacco products could be used to promote a cigarette brand. Due to companies’ efforts to circumvent the policies by frequent change of price announcements that could be construed as advertising - a 2011 regulation called for tobacco products to be kept in closed places or boxes and not visible to the customer. The cashier would have to provide the product upon request.

Additional tobacco control initiatives allowed tobacco companies to make charitable donations, but prohibited them from announcing or advertising their contributions publicly.

Turkish-owned media companies were directed to devote at least 90 minutes of programming per month to informing the public about the hazards of tobacco use. There were guidelines on the timing of these public service announcements to ensure that they would be seen or heard in prime time. Further, an educational curriculum was developed to instruct students on the dangers of tobacco use. More recently a public media campaign was created in Turkey with hard-hitting ads portraying the impact of tobacco use.

The economic industry forecasters project that rising health awareness and increasing prices have resulted in reduced smoking in Turkey. The industry’s value increased in 2011 as a result of unit prices; however, volume sales recorded a decline caused by a reduction in cigarette sales – the most frequently used tobacco product in Turkey. As a result of aggressive action to turn around the tobacco epidemic, Turkey has been widely recognized in the global public health

sector as a leader in tobacco control. However, the impact of these policies is just taking hold and the long-term effects of these policies will require monitoring and evaluation.

1.8 Summary

This introductory chapter provided an overview of the tobacco epidemic and its resulting impact on low and middle-income countries. The purpose of the research study is explained as an examination of the impact of tobacco advertising, promotion and sponsorship in African countries and the effect of efforts to avert a tobacco epidemic through policies that ban TAPS.

Additionally, the impact of TAPS in Turkey and Thailand will be analyzed along with the effect of these country’s tobacco control policies on addressing the epidemic. A detailed description of the tobacco situation in each country is provided for contextual background for the proposed research design and expected outcomes.

Table 1.4 Turkey and Thailand: Country Profile, Tobacco Control Timeline ACTIVITY YEAR THAILAND YEAR TURKEY First Tobacco 1992 Tobacco Control Product Act & Non-smokers’ Health Protection 1996 Law 4207 considered weak and unenforced Control Law Act B.E. 2535 - Enforcement weak - Ban on advertising, promotion, sponsorship – exceptions - Regulate public indoor smoking-designated non-smoking areas - Regulate product packaging and pictorial warning labels - Public education campaigns - Cessation assistance FCTC Ratified 2004 Ratified November 8, 2004 2004 Ratified December 31, 2004 National Tobacco 1989 The National Committee for the Control of Tobacco Use formed 2006 Prime Minister launched the National Tobacco Control Program under the Ministry of Public Health Control Programme and Action Plan of Turkey for established 2008 – 2012 Subsequent Tobacco 2002 - Amendments to expand and enforce the laws: 2008 Amended Law 4207 to become one of the leading Control Legislation 2010 - Expanded the warning label size and graphical content tobacco control laws worldwide: - Comprehensive ban on public indoor smoking - Comprehensive ban on advertising, promotion, - Prohibit point of sale display – product advertising sponsorship – few loopholes - Prohibit public indoor smoking - Regulate product packaging and warning labels - Public education campaigns - Penalties for violations GATS – 1st Round 2009 Male smoking prevalence – 45.6 percent 2008 Male smoking prevalence – 47.9 percent Female prevalence – 3.1 percent Female prevalence – 15.2 percent Overall – 23.7 percent Overall – 31.3 percent GATS – 2nd Round 2011 Male smoking prevalence – 46.6 percent 2012 Male smoking prevalence – 41.4 percent Female prevalence – 2.6 percent Female prevalence – 13.1 percent Overall – 24.0 percent Overall – 27.0 percent Additional Tobacco 1993 Excise tax levied for health reasons – fund health promotion 2012 Price of tobacco increased above inflation. Cigarettes Control Measures National Tobacco Control Policy – to reduce smoking to 21 taxed at 78 percent of retail price (2/2012) 2002 percent by 2006; prevent youth initiation; protect from SHS; reduce per capita consumption Amended Tobacco 2012 Increased taxes on manufactured cigarettes – taxed at 69 percent 2012 Additional amendments to Law 4207 passed: Control Legislation of retail price (2/2012). Roll-your-own cigarettes lower priced. - Banned indirect advertising of logos, names, designs, etc. on non-tobacco products - Banned tobacco sales to minors under 18 - Pictorial warning on water pipes - Municipal police authorized to impose penalties

CHAPTER 2

LITERATURE REVIEW

2.0 Literature Review Part One

This first review is to examine the literature related to the impact of exposure to tobacco advertising, promotion, and sponsorship (TAPS) and policies that ban TAPS on adolescents in low and middle-income African countries.

2.0.1 Purpose

The purpose of this review is to assess the effect of Article 13 of the World Health

Organization (WHO) Framework Convention on Tobacco Control – which broadly addresses the regulation of tobacco advertising, promotion and sponsorship (TAPS). The review will specifically focus on the impact of Article 13 on adolescents in low and middle-income African countries. Further, the review will include a critique of the published research on the impact of

TAPS and anti-TAPS policies in African countries and how the tobacco’s industry influences tobacco policies and behavior in low and middle-income countries.

2.0.2 Background

Tobacco is a highly marketed commodity; manufacturers effectively market their product, particularly cigarettes, by advertising via all forms of media, employing promotional activities such as price discounts, branded gifts items or logo placement in movies, and sponsorships of events or community causes. The aim of advertising cigarettes is to create a social norm wherein smoking is familiar, enjoyable and acceptable. Research studies have documented that TAPS exposure increases tobacco use, hence, cigarettes continue to be one of

the most heavily marketed consumer product. In the 2011, the industry spent $8.4 billion on

TAPS in the U.S. alone (CDC, 2013).

In response to the increasingly aggressive marketing of cigarettes, the WHO FCTC incorporated Provision 13 which sought to control tobacco use by requiring the following actions by parties to the Treaty:

As a minimum, and in accordance with its constitution or constitutional principles, each Party shall:

(a) prohibit all forms of tobacco advertising, promotion and sponsorship that promote a tobacco product by any means that are false, misleading or deceptive or likely to create an erroneous impression about its characteristics, health effects, hazards or emissions;

(b) require that health or other appropriate warnings or messages accompany all tobacco advertising and, as appropriate, promotion and sponsorship;

(c) restrict the use of direct or indirect incentives that encourage the purchase of tobacco products by the public;… (WHO, 2003)

The WHO FCTC provides additional definitions and guidelines for implementing Article 13 which says: According to the definitions in Article 1 of the Convention, a comprehensive ban on all tobacco advertising, promotion and sponsorship applies to all forms of commercial communication, recommendation or action and all forms of contribution to any event, activity or individual with the aim, effect, or likely effect of promoting a tobacco product or tobacco use either directly or indirectly.

(d) A comprehensive ban on tobacco advertising, promotion and sponsorship should include cross-border advertising, promotion and sponsorship. This includes both outflowing advertising, promotion and sponsorship (originating from a Party’s territory) and in-flowing advertising, promotion and sponsorship (entering a Party’s territory).

(e) To be effective, a comprehensive ban should address all persons or entities involved in the production, placement and/or dissemination of tobacco advertising, promotion and sponsorship. (WHO, 2008)

2.0.3 Conceptual Framework

Causal relationship of TAPS and smoking

Scientific analyses of the literature on the effects of cigarette advertising suggest a causal relationship with tobacco consumption. The most recent and comprehensive analyses of the supporting evidence for this position was published in the National Cancer Institute Monograph

19 and the Cochran Collaboration Systematic Review.

In 2008, the U.S. National Cancer Institute (NCI) published Monograph Nineteen entitled

The Role of the Media in Promoting and Reducing Tobacco Use. The Monograph was a critical scientific review and synthesis of the current evidence related to the impact of media and tobacco use. One the primary conclusions of this review states that “the total weight of the evidence from many countries demonstrates a causal relationship between advertising and promotion and increased tobacco use.” The review further concludes that the “total weight of evidence from cross-sectional, longitudinal, and experimental studies indicate a causal relationship between exposure to depictions of smoking in movies and youth smoking initiation.”

Subsequently, the Cochrane Collaboration conducted a systematic review of longitudinal studies in 2011 to assess the effects of tobacco advertising and promotion on nonsmoking adolescents’ future smoking behavior. The review found that in all the studies analyzed, nonsmoking adolescents who were more aware of or receptive to tobacco advertising were more likely to have experimented with cigarettes or become smokers at follow up. Studies also revealed that adolescents smokers’ cigarette brand choices directly correlated with the three most heavily advertised brands in the U.S.

One US-based study cited by the Cochrane review analyzed the difference between smoking susceptibility and uptake of cigarettes among various ethnic groups (Cochrane, 2008).

No association between susceptibility and advertising exposure was found in African American and Hispanic students whereas a positive association was found in white students.

However, the 19 studies included in the Cochrane review as well as the vast majority of resources used in the NCI Monograph 19 came from studies conducted in high-income, developed countries. Thus the conclusions formed from these landmark reviews did not include the population of interest – adolescents in low and middle income African countries.

Impact of policies that restrict TAPS on smoking

According to the research, countries that enact comprehensive TAPS bans prohibiting the marketing of cigarette via advertising, promotion and sponsorship, can reduce tobacco consumption (Saffer, 2000). Partial bans appear to be less effective as the industry tends to find loopholes in the weaker policies and use alternate marketing strategies to promote their product.

Economic studies on the effect of TAPS bans on tobacco consumption have been controversial as mixed results have been found. Saffer (2000) studied 22 developed countries and his model found that comprehensive or total bans reduced tobacco consumption by 6.3% in adults while partial bans (which allowed limited promotion) resulted in a 1% decrease in consumption.

Bleecher (2008) conducted an economic analysis which included 30 developing countries and found that partial marketing bans were associated with a 13.6 percent decrease in tobacco use and comprehensive bans showed a 25.3% decrease. The data used for this model, which focused on adult consumption, were gathered between 1990 and 2003 and was unavailable for many countries.

Thus this review will focus on the impact of TAPS exposure and TAPS policies on adolescents in low and middle income African countries.

2.0.4 Methods

Google Scholar, Web of Knowledge, and the Centers for Disease Control and Prevention, Office on Smoking and Health online database.

Inclusion Criteria

Criteria required for study selection were the following:

1. Focus on research related to: i) the impact of adolescent exposure to tobacco

advertising, promotion and sponsorship in low and middle-income African

countries; ii) the impact of tobacco use and control policies on adolescents in

African low and middle-income countries; and iii) the tobacco industry’s marketing

strategies in low and middle-income countries with a primary focus on African

countries.

2. Include resources that focus on adolescents between the ages of 10 and 19 years

old. Adolescence has no scientific classification or set age boundary, however, the

World Health Organization defines adolescents as being between 10 and 19 years

(WHO, 2013).

3. Include articles published in the English language between 2002 and 2013 (within

the past decade after FCTC adoption);

4. Include all research designs, i.e. randomized-controlled trial, quasi-experimental,

non-randomized controlled, observational pre and post legislation, interrupted time

series, and qualitative studies, and review studies published in a peer-reviewed

journal;

5. Exclude research conducted or funded by the tobacco industry due to potential bias.

Key Words

Key words and terms used in this literature search were: cigarette smoking/tobacco use, tobacco behavior/attitude, adolescents/child/students, tobacco advertising/promotion/ sponsorship/marketing, Africa, tobacco policy/laws/legislation/bans/restrictions, tobacco industry.

Data Extraction

Each article was evaluated based on the inclusion criteria. Relevant articles were reviewed in depth and the following data were extracted and analyzed: study purpose; country of origin; sample description and size; control group; study period; outcome measures; research design; findings; and methodological limitations. After an in-depth review of each relevant article, studies were further narrowed to focus on low and middle income countries where impact of tobacco marketing and tobacco control policies had been assessed with statistically validated outcomes reported in the article.

2.0.5 Literature Review Results

The initial database search produced scores of articles related to the level of adolescent exposure to TAPS only 38 studies focused on youth in low and middle-income African countries. Generally there was wide consensus that TAPS exposure in adolescents affected tobacco awareness and attitude. However, there were differences in the findings related to TAPS exposure and behavioral impact.

Of the 38 studies reviewed 33 were focused on the impact of TAPS in Africa (see Table

2.1) the countries or regions included were: Botswana, the Gambia, Ghana, Kenya, Liberia,

Malawi, Namibia, Nigeria, Senegal, Seychelles South Africa, Sudan, Swaziland, Tanzania,

Tunisia, Uganda, Zimbabwe, Zambia and Northern Africa.

Within the 33 studies that analyzed the impact of adolescent exposure to TAPS in Africa, the most common research design was cross-sectional studies; of these eight analyzed national or regional data from Global Youth Tobacco Surveys in various African countries (Bandasen, 2010;

Madkour, 2013; Mamudu, 2013; Mpabulungi, 2006; Muula, 2007; Siziuya, 2007; Viswanathan,

2008; Zulu, 2009). Five studies conducted literature reviews related to the prevalence of tobacco use in adolescents (Kaguruki, 2010; Nwhator, 2012; Nrturibi, 2008; Osusu-Dabo, 2009;

Townsend, 2006). Two studies involved longitudinal follow up of adolescent cohorts to determine predictors of smoking initiation (Harabi, 2009; Mashita, 2011). A qualitative research study involved focus groups of adolescents seeking feedback on their support for tobacco control programs and exposure to advertising and smoking (Swart, 2006). The remaining studies were cross-sectional primary data collection from adolescents from various regions within Africa.

Five articles addressed the marketing strategies used by the tobacco industry to reach youth in low and middle-income African countries (see Table 2.2). These articles were mainly literature reviews or commentaries on the economic and political actions and marketing promotions used to affect or prevent tobacco control policies.

Finally two resources were reviewed that focused on the impact of tobacco policies that control TAPS in low and middle income countries (see Table 2.3). The findings of this case study (Mullin, 2011) and literature review (Nagler, 2013) provide a solid evidence base in support of the FCTC call for policies that ban TAPS. The authors conclude that greater

awareness of the dangers of smoking leads to increased cessation-related attitudes and behaviors in low and middle income countries. However, neither of these resources involved nor focused on African populations and no related studies conducted in an African country were found.

The findings of this review document the high level tobacco advertising and promotion exposure that exists for African youth (Doku, 2012; Madkour, 2013; Mamudu, 2013; Mashita,

2011; Mpabulungi, 2006; Muula, 2007a, Muula, 2007b; Siziya, 2007; Viswanathan, 2008; Zulu,

2009). Some countries, particularly in Northern Africa noted increased male smoking prevalence over time (El-Amin, 2011; El Mhamdi, 2011; Mashita, 2011; Muula, 2007a; Pamper,

2005; Pelzer, 2011; Townsend, 2006) and found that males smoked at much higher rates than females. A strong association between family relations or smoking behavior and youth smoking was found across the board (Adebiyi, 2010; Bandason, 2010; Brook, 2006; Doku, 2010; Doku,

2012; El-Amin, 2011; ElMhamid, 2011; Harrabi, 2009; King, 2011; Mamudu, 2013; Mashita,

2011; Muula, 2007; Pelzer, 2011; Siziya, 2007). Several studies demonstrated an association between experimentation with smoking and exposure to cigarette advertising or observing smoking on TV (Brook, 2009; Madkour, 2013; Mamudu, 2013; Mashita, 2011; Siziya, 2011;

Zulu, 2009). There were conflicting findings, particularly in Ghanaian-based studies (Doku,

2010; Doku, 2012; Owusu-Dabo, 2009) where relatively low prevalence of adolescents smoking was reported even though TAPS exposure was high. The authors concluded that societal norms, cultural values and unfavorable economic conditions were factors that restricted adolescent smoking.

South African studies found that smoking behavior and attitudes differed by ethnicity – black youth tended to smoke less and had a weaker association between nicotine dependence and receptivity to media models of smoking than other ethnic groups (Brook, 2006; Brook, 2009;

Panday, 2007). However, family and peer influence were associated with youth smoking across all South African ethnicities (Pahl, 2010).

A number of limitations were noted, including: the narrow scope of several studies – e.g. limited to a city, or small region and thus the results could not be generalized. A number of studies and reviews noted a lack of adequate tobacco-related data for the region or country

(Nwhator, 2012; Nrturibi, 2008). A number of studies used outdated data prior to adoption of the FCTC (Harrabi, 2009; Mpabulungti, 2006; Muula, 2007a; Muula, 2007b; Panday, 2005;

Panday, 2007; Pelzer, 2009; Siziya, 2007; Townsend, 2006; Viswanathan, 2008) Finally, no studies linked their findings to TAPS policies within their country or measured differences in exposure or behavior over time based on a change in tobacco control policy.

2.0.6 Discussion and Conclusion

The weight of the evidence suggests an association between tobacco advertising, promotion and sponsorship and smoking in adolescents in Africa - although there were conflicting results by country. Familial and peer relationships also correlate with tobacco consumption – adolescents were more likely to smoke if family or friends did. Economic conditions may play a significant role in smoking prevalence – as it affects affordability of cigarettes. There are gaps in the research specifically related to the impact of TAPS bans on smoking in adolescents in Africa.

Additional research is needed that assesses the impact of TAPS policies on adolescent smoking behavior in African countries over time. This is required to evaluate the effectiveness of these policies and assist in modifications that would enhance their intended outcome. Further, studies that monitor the influence of the tobacco industry’s marketing strategies are needed to provide information that will aid policymaker’s ability to successfully regulate TAPS and assure compliance with related policies.

Reduced adult Reduced adult Positive adult tobacco use influence on exposure to TAPS adolescents to avoid tobacco use

Tobacco Policies:

Advertising, Reduce adolescent Reduced influence Promotion, Reduced adolescent exposure to TAPS on adolescents to tobacco use Sponsorship initiate tobacco (TAPS) Bans use

Tobacco Industry Reduced impact of Increased tobacco devises means of policy use skirting policies Effect Modifiers: - Laws (comprehensive, partial, weak) - Enforcement/ Political will - Compliance/Acceptance - Counter tobacco Advertising

Figure 2.1 Conceptual Approach for Assessing Impact of Tobacco Advertising, Promotion, Sponsorship Policy/Legislation

Table 2.1: Adolescent Exposure to and Impact of Tobacco Marketing in Low & Middle-Income African Countries Citation Purpose Sample Study Research Design Findings Limitations Description Period 1 Adebiyi A, Faseru B. (2010). To provide a template A sub-sample of ? A descriptive cross Peer influence is an Limited study “Tobacco use amongst out of for the derivation of a 215 out of school sectional study – important source of population school adolescents in a Local theory-based approach adolescents from a questionnaire - introduction to Government Area in Nigeria.” to researching and descriptive cross administered - ? tobacco. Selling of Substance Abuse Treatment, understanding sectional study tobacco to Prevention, and Policy; Vol. 5 adolescent tobacco use among youth in adolescents was No.24 as the basis for two communities common. effective policy in a Local formulations Government Area in Nigeria 2 Bandason T, Rusakaniko S. To estimate and Randomly 2009 Cross sectional Smoking associated Cross sectional data (2010). "Prevalence and characterize the selected classes in school based with having friends associated factors of smoking prevalence, and 6 participating survey (GYTS+) who smoke, getting among secondary school students associated factors, of schools - 650 involved in physical in Harare, Zimbabwe." Tobacco smoking among urban students mean age fights, alcohol use, Induced Diseases: Vol. 8; No. 12 students in Zimbabwe. of 16 years marijuana use, having had sex 3 Brook J, Morojele N, et al. To examine the Adolescents (ages ? Cross-sectional Factors in all 4 External social (2006) “Personal, interpersonal, personal, parental, 12-17) in J’burg data collected via domains significantly influences did not and cultural predictors of stages peer, and cultural communities structured in- predicted the 3 stages include tobacco in of cigarette smoking among predictors of stages of N= 731 person interview of smoking. media – ads or adolescents in Johannesburg, smoking (non- 4 ethnicities promotions South Africa.” Tobacco Control. smoking, Vol.15; Suppl. I: i48-i53 experimental, regular)

4 Brook J, Pahl K, et al. (2009). To determine the Stratified random ? Structured There was a positive Cross sectional data “The relationship between association of sample of 12-17 questionnaire relationship between Small sample size for receptivity to media models of receptivity to media years olds in conducted in the media receptivity and white adolescents. smoking and nicotine models of smoking Johannesburg, home – receptivity nicotine dependence. dependence among South and nicotine SA. to media models of Strongest among African adolescents.” Addiction dependence among 731 adolescents smoking assessed whites and weakest Research & Theory Vo. 17 No. 5: South African with 3-item Likert among blacks – 493-503 adolescents from 4 scale. Nicotine although they were ethnic groups dependence equally receptive. assessed with the Fagerstrom Test.

Citation Purpose Sample Study Research Design Findings Limitations Description Period 5 Doku D, Koivusilta L, et al. To investigate SES Representative 2008 Cross sectional SES differences Limited to school (2010). "Do socioeconomic differences in smoking sample of 1,165 self-administered existed in tobacco students/ cross- differences in tobacco use exist and tawa use among 13 - 18 year old survey use- lower SES and sectional data also in developing countries? A Ghanaian adolescents; students from living in a non- study of Ghanaian adolescents." also to explore how three regions in nuclear family BMC Public Health 2010: the inter-generational Ghana; 30 schools associated with Vol.10; No.758 social mobility related randomly selected tobacco use in to tobacco use. adolescents.

6 Doku D, Koivusilta L, et al. To explore exposure to Randomized 2008 Analysis of Smoking rates were Higher prevalence of (2012). “Tobacco use and tobacco promoting or representative primary data relatively low and smoking was found exposure to tobacco promoting restraining factors and sample of 13- 18 collected via exposure to tobacco in students whose and restraining factors among their associations with year old school school-based advertising was high. parents smoke. adolescents in a developing smoking and tawa use students -1165. representative Societal norms or Further study needed country.” Public Health: 126 among 13-18 year old Convenience survey of 13-18 cultural values seem on cultural values (2012) 668-674 Ghanaians. sample of 127 year old Ghanaian to restrict smoking versus governmental non-students. students and a and access to policies on tobacco convenience tobacco. use. sample of non- students

7 El-Amin SE, Nwaru B, et al. To assess the influence Representative 2005-2006 Cross sectional Smoking habits Cross sectional data (2011). "The role of parents, of smoking and sample of 4277 school based associated with habit friends and teachers in tombak dipping by students between survey (GYTS +) in parents, adolescents' cigarette smoking parents, teachers and 11-17 years old teachers, and friends. and tombak dipping in Sudan." friends on tobacco use from 23 schools in Compared to 2001 Tobacco Control 2011; Vol. 20: in Sudanese students. Khartoum survey smoking 94-99 increasing among doi:10.1136/tc2010.038091 students

8 El Mhamdi S, Khiari-Wolfcarius To estimate smoking Adolescents from 2004 Observational Significantly higher Limited to students G, et al. (2011). “Prevalence and prevalence and 8 colleges and cross-sectional male smoking no measurement of predictors of smoking among analyze the high schools aged study – prevalence, behavior exposure to ads adolescent school children in determinants of 10 -19 years. self- administered initiated by peer Monastir, Tunisia.” Eastern tobacco use among N=900; mean age questionnaire influence- mean age Mediterranean Health Journal; adolescents. 15.8 at first smoking Vol. 17; No. 6; 523-528 experience- 13.8

Citation Purpose Sample Study Research Design Findings Limitations Description Period 9 Harrabi I, Chahed H, et al. To identify predictors Cohort of 13-15 1993, 2003 Cohort Predictors associated Not sure if tobacco (2009). "Predictors of smoking of smoking initiation year old students longitudinal survey with smoking marketing was initiation among school children among non-smoking attending schools initiation: Previous included in analyses. in Tunisia: a 4-years cohort Tunisian school in Sousse City in experimentation with study." African Health Sciences; children 1999 N=789; tobacco and alcohol, Vol. 9; No. 3; 147 - 152 repeated in 2003 having a smoking by students best friend, lack of N=453; 441 sensitization from the students had school, and positive initially view of smoking. participated. 10 Kagaruki L. (2010) “Community- Review of tobacco use N/A ? A review 35% of Tanzanians Data from based advocacy opportunities for and control in smoke and 32% of unpublished sources tobacco control: experience from Tanzania cancers at a Cancer Tanzania.” Global Health Institute are tobacco Promotion. Supp. 2: 41-44 related. 3rd highest tobacco producer in Africa 11 King G, Gilreath T. et al. (2011) To examine the roles Black male ? Cross-sectional Lower prevalence Limited population “Smoking among high school of families, students from 41 data – than urban males in scope. Time of data male students in rural South community influences, randomly selected questionnaire SA. Family structure, collection unknown. Africa.” Journal of Substance key socio- school from a administered by lack of discipline Use. Vol. 16;No. 4: 282-294 demographic factors convenience field workers. associated with and school-age sample of rural smoking. smoking in males in districts of SA. rural South Africa N=1116

12 Madkour AS, Leford EC, et al. To examine the Nationally 2005-2007 Secondary data Tobacco advertising/ Cross-sectional data (2013). “Tobacco association between representative analysis of Global promotion exposure – reverse causality is advertising/promotions and advertising/promotions sample of North Youth Tobacco was highly prevalent possible - Students adolescents’ smoking risk in exposure and African school Survey and associated with who smoke may be Northern Africa.” Tobacco adolescent smoking students (Egypt, administered to adolescents’ smoking more likely to notice Control 2013; -:1-9. risk in North Africa Tunisia, Libya, primary and risk in these promotions Doi:10.1136/tobaccocontrol- and possible mediation Morocco, and secondary students countries. 2012-050593 of this association by Sudan) sample in 5 North African parent and peer size 12,329 countries. smoking.

Citation Purpose Sample Study Research Design Findings Limitations Description Period 13 Mamudu H, Veernanki S, John To assess tobacco use Nationally 2006 Secondary data Youth tobacco use Cross-sectional data R. (2013). “Tobacco Use Among among school-going representative analysis of Global associated with School-Going Adolescents (11- adolescents and sample of school Youth Tobacco tobacco industry 17 Years) in Ghana.” Nicotine & delineate determinants students in Ghana Survey. promotions and Tobacco Research; Vol. 15, No. of their tobacco-use age 11-17. Sample tobacco use of 8; 1355-1364 status size 9,990 familial relations.

14 Mashita R, Themane M, et al. To explore the Poor rural 2003-2005 Longitudinal study Prevalence increased SES was not factored (2011) “Current smoking association between students in SA – questionnaire in boys. Parents into analyses. Not behavior among rural South tobacco use and habits, Ages 11-18 significant influence linked to policies. African children: Ellisras attitudes and beliefs in N= 1771 in 2003 on behavior. TV Longitudinal Study.” BMC SA children N= 1654 in 2005 actors smoking Pediatrics. Vol.11; No. 58 associated with smoking, women who smoked associated with wealth and success

15 Mpabulungi L, Muula,AS. To determine smoking School students 2001 Cross-sectional Relatively high Study population (2006). “Tobacco use among prevalence, exposure 13-15 years from descriptive study prevalence across limited in scope. In high school students in a remote to ads and SHS, a sample of 25 (GYTS gender, 60% this area 41% of district of Arua, Uganda.” Rural smoking deterrents schools in remote questionnaire) purchased tobacco at school aged children and Remote Health; Vol. 6; 609 and perceptions in district of Uganda stores; media were enrolled in high school students (tobacco farming exposure high; high school. area) tobacco production N= 1528 area

16 Muula AS. (2007). “Prevalence To determine the Public school 2001 Cross-sectional Predictors of current Study population and determinants of cigarette prevalence and students in descriptive study smoking – male, limited in scope. smoking among adolescents in determinants of Blantyre City. 13- (GYTS smoking peers and Blantyre City, Malawi.” smoking in Blantyre 15 years old questionnaire) parents, exposure to Tanzania Health Research City, Malawi. N=1308 ads. Bulletin; Vol. 9. No.1; 48-50 Being taught about tobacco dangers and class discussions not associated with use.

Citation Purpose Sample Study Research Design Findings Limitations Description Period 17 Muula A, Mpabulungi L. (2007). To compare School students 2001-2002 Cross-sectional Students in Lilongwe Study population “Cigarette smoking prevalence prevalence of tobacco 13- 17 years old descriptive study more likely to have limited in scope. among school-going adolescents use and exposure to N= 1820 (GYTS ever smoked and to in two African capital cities: tobacco and tobacco Lilongwe questionnaire) start within a year. Kampala Uganda and Lilongwe related issues among N= 2789 Kampala Exposure to ads high Malawi.” African Health adolescents in two in both cities. Uganda Sciences; Vol.7 No. 1; 45-49 urban African cities. has ban on ad – unenforced – both tobacco producing countries

18 Nwhator S. (2012). “Nigeria’s To review 25 years of Review of studies, ? Literature review Inadequate Limited data costly complacency and the Nigeria’s tobacco databases, monitoring of available – global tobacco epidemic.” control policy and documents in tobacco use- rising Data not comparable Journal of Public Health Policy; tobacco use. Nigeria smoking prevalence - Vol. 33 No. 1: 16-33 all ages and gender

19 Nrturibi E, Kolawole A, Review of the Published ? Computerized High prevalence of Many of the McCurdy S. (2008) “Smoking literature to identify literature and search and review. smoking in Kenya, prevalence estimates prevalence and tobacco control smoking prevalence in information found Uganda, Gambia. No were prior to 2004 measures in Kenya, Uganda, the each country. on health data for Liberia. Gambia, and Liberia: a review.” Review of tobacco department and Tobacco control Int. Journal of TB and Lung control measures WHO websites. measures were Disease. Vol.13; No. 2; 165-170 found in health inadequate – only department reports. Kenya had enacted strong anti-tobacco legislation in 2007

20 Owusu-Dabo E, Lewis S, et al. To explore the history Review of 2007 Iterative literature Although the industry (2009) “Smoking in Ghana: a of tobacco industry documents review was active for 50+ review of tobacco industry archives and other years, a combination activity.” Tobacco Control; Vol. local sources to obtain of advertising bans 18: 206-211 data relevant to and unfavorable marketing and con- economic conditions sumption of tobacco restricted growth.

Citation Purpose Sample Study Research Design Findings Limitations Description Period 21 Owusu-Dabo E, Lewis S, et al. To investigate the Ashanti region of 2007-2008 Randomized Smoking prevalence Sample had high (2009) “Smoking uptake and extent and Ghana residents representative relatively low despite proportion of females prevalence in Ghana.” Tobacco determinants of aged 14 + household survey. tobacco industry to males – 63.7% Control; Vol. 18: 365-370 tobacco use in 6258 – sample presence. female Ghana’s Ashanti size Higher prevalence region (most heavily among low SES populated area)

22 Pahl K, Brooks D, et al. (2010) To examine the Adolescents (ages ? Cross-sectional Higher levels of Cross sectional; “Nicotine dependence and relationship between 12-17) in J’burg data nicotine dependence limited variables problem behaviors among urban nicotine dependence communities In-person significantly predicts studied South African adolescents.” and adolescent N= 731 individual higher levels of Journal of Behavioral Medicine. problem behaviors Mean age 14.55 interview violent behavior, Vol. 33: 101-109 4 ethnicities other drug use, unsafe sex – across gender/ethnicity

23 Pampel F. (2005) “Patterns of To examine Database from 2000-2002 Secondary data Male users less Outdated tobacco Use in the Early demographic and SES Demographic analysis – educated, urban, Epidemic Stages: Malawi and patterns of tobacco use Health Surveys - multinomial formerly married, Zambia.” American Journal of in 2 African nations in men 15-19 logistic regression non-Christian, non- Public Health. Vol. 95; No. 6: the early stages of N=5111; women models Muslim. Women 1009-1015 epidemic 15-49 N=20,809 much lower prevalence but also less educated and lower occupational status

24 Panday S, Reddy P. et al. (2005) To explore the Adolescents 2002 Cross-sectional – Former smokers more Cross sectional data “Determinants of smoking determinants of monthly and self-administered positive attitude to – no causal links cessation among adolescents in smoking cessation former smokers survey. non-smoking, South Africa.” Health Education among a sample of ages 14-16 – Used the I-Change supportive social Research. Vol. 20 No. 5: 586-599 adolescent smokers students in Cape- Model (integrated environment, higher and former smokers Karoo region of model of change to self-efficacy, positive SA. measure about intentions not 3 ethnicities determinants of to smoke N= 4768 smoking cessation

Citation Purpose Sample Study Research Design Findings Limitations Description Period 25 Panday S, Reddy P, et al. To investigate the Adolescents 2002 Cross-sectional – Non-smokers more Cross sectional data (2007)”Determinants of smoking factors related to monthly and self-administered positive attitude to among adolescents in the smoking among former smokers survey. non-smoking, Southern Cape-Karoo region, adolescents. ages 14-16 – Used the I-Change supportive social South Africa.” Health Promotion students in a Model (integrated environment, higher International. Vol. 22; No. 3: region in South model of change to self-efficacy, positive 207-217 Africa – 3 measure about intentions not ethnicities determinants of to smoke. Differences N= 3378 smoking by ethnicity. Blacks lower scores on pros of non-smoking 26 Pelzer K. (2009) “Prevalence and To assess the Students age 13- 2003-2004 Secondary analysis Mental distress, Cross sectional correlates of substance use prevalence and 15 years of Global School- truancy, poverty among school children in six correlates of substance N= 20, 765 Based Health associated with African countries.” International use among students in (Kenya, Namibia, Survey (GSBH). substance use. Journal of Psychology. Vol. 44; 6 African countries. Swaziland, Questionnaire. No. 5: 378-386 Uganda, Zambia, Zimbabwe) 27 Pelzer K. (2011) “Early smoking To examine the National ? Secondary analysis Overall 15.5% Social influences initiation and associated factors prevalence and representative of GSBH survey. smoked before 14. such as advertising, among in-school male and female common correlates of samples of (20% boys; 11% promotion not adolescents in seven African early smoking students 13- 15 girls) included. countries.” African Health initiation among years Early initiation Sciences. Vol. 11; No. 3: 320- students in 7 African N= 17,725 associated with ever 328 countries (Botswana, drunk from alcohol, Kenya, Namibia, sex, parental tobacco Senegal, use and suicide Tanzania, ideation. Uganda, Zimbabwe) 28 Rantao M, Ayo-Yusuf O. (2012) To determine factors Black African 2005 Secondary analysis Dual users more Cross sectional data “Dual Use of Cigarettes and associated with dual students – 8 grade – nested study – likely vulnerable to – no causal links Smokeless Tobacco among South use of tobacco in rural SA cross sectional depression, binge African Adolescents.” American products in a popula- N= 1878 drinking, cannabis Journal of Health Behavior. Vol. tion of black SA use, and attend 36 No. 1: 124-133 adolescents. schools with no smoking regulations

Citation Purpose Sample Study Research Design Findings Limitations Description Period 29 Siziya S, Rudatsikira E, et al. To estimate prevalence Analyzed Global 2002 Cross sectional Parental smoking, Cross sectional data (2007). "Predictors of cigarette of those who have Youth Tobacco school-based friends smoking, a smoking among adolescents in smoked cigarettes and Survey among 13 survey lack of knowledge, rural Zambia: results from a cross to identify associated - 15 year old and exposure to pro- sectional study from Chongwe socio-demographic students tobacco district." Rural and Remote factors among advertisements were Health: Vol. 7; No. 728 adolescents in associated with Chongwe district, having smoked Lusaka Province, cigarettes. Zambia 30 Swart D, Panday S, et al. (2006) To explore adolescent 12 – 14 adolescent ? 12 Focus groups of Similar preference for “Access point analysis: what do preferences for key students in randomly selected cessation and adolescents in South Africa say elements of tobacco Southern Cape- students- prevention programs about tobacco control control programs – Karoo region of prevention study School-based programmes?” Health Education prevention and SA 9 groups - programs supported Research. Vol. 21; No. 3: 393- cessation 117 students cessation study by community-based 406 Structured guides mass media/comprehensive approaches

31 Townsend L, Flisher A. (2006) To provide a synthesis Youth tobacco use 1990-2004 Review 45 articles from 15 of Data prior to FCTC “A systematic review of tobacco of prevalence data in related articles 48 African countries. use among sub-Saharan African among young people from relevant -SA highest use youth.” Journal of Substance in sub-Saharan Africa; databases. -male higher use Use. Vol. 11; No. 4: 245-269 examine factors -higher SES higher associated with risk tobacco use; identify gaps in research.

32 Viswanathan B, Warren C. et al. To present data from A representative 2002 Cross-sectional >25% current Cross sectional data (2008) “Linking Global Youth the 2002 Seychelles sample of students descriptive study smokers likely Tobacco Survey Data to the GYTS and show that it ages 13-15 (GYTS predicts increasing WHO Framework Convention on can be a tool for N= 1321 questionnaire) prevalence as Tobacco Control: The Case for monitoring and students become Seychelles.” Preventive strengthening tobacco adults – including Medicine. Vol. 47 S33-S37 control programs women. Exposure to ads high although ban in place since 1999.

Citation Purpose Sample Study Research Design Findings Limitations Description Period 33 Zulu R, Siziya S, et al. (2009). To assess baseline Sample of 2678 2007 Secondary data TV ads, promotion, Data limited to “Associations of advertisement- exposure to cigarette primary/secondary analysis of Global sponsorship was school students in promotion-sponsorship-related advertising and if students – 2378 Youth Tobacco positively associated one city; cross factors with current cigarette exposure was participated Survey with smoking while it sectional data cannot smoking among in-school associated with current administered to was the opposite with provide causal links. adolescents in Zambia” Annals of smoking. primary and other forms of Little information re African Medicine: Vol. 8, No. 4; secondary students advertising Zambia’s tobacco 2009: 229-235 in the city of policies Lusaka.

Table 2.2: Tobacco Industry Marketing Strategies in African Low and Middle-income Countries Citation Purpose Sample Study Research Findings I. Limitations Description Period Design 1 Doku D. (2010). “The tobacco A commentary on the Significant challenges industry tactics – a challenge for current situation in remain for African tobacco control in low and African countries countries attempting to middle income countries” faced with combating implement the FCTC African Health Sciences, Vol. 10 the tobacco industry provisions (2) 201-203 tactics. 2 Jakpor P. (2012). “Nigeria: how A commentary on the Analysis of the Increase awareness of British American Tobacco industries response to corporate social implications of undermines the WHO FCTC pending legislation in responsibility government/ industry through agricultural initiatives: Nigerian parliament program of the partnerships invited commentary” Tobacco industry Control, Vol.21(2) p220 3 Lee S, Ling P, Glanz, S. (2012). To understand Literature review 2011 Systematic Industry strategies in “The vector of the tobacco transnational tobacco literature review LMIC follow 4 main epidemic: tobacco industry companies’ practices themes: practices in low and middle- in low and middle- -economic activity income countries” Cancer income countries -marketing/promo Causes Control, Vol. 23 117-129 which serve to block -political activity tobacco-control -deceptive/manipul- policies and promote ative activities tobacco use. 4 Panday S, Richter L, Bhana A. A commentary on Need for additional (2006). “Young adults, the target how the industry’s restrictions to close of below-the-line advertising” shifted its focus from loopholes in the laws. South Africa Medical Journal, direct to indirect Vol.6(2) 104-105 advertising after the comprehensive TAPS ban in South Africa 5 Patel P, Okechukwu C, Collin J, A review of music An analysis of 1990-2001 Systematic review Findings illustrate the Hughes B. (2009). “ Bringing sponsorship to market previously secret scale of the challenge, ‘Light, Life and Happiness’: cigarettes in sub- corporate with music sponsorship British American Tobacco and Saharan African and documents from demonstrating a capacity music sponsorship in sub- illustrate 2 case British American to undermine even the Saharan Africa” Third World studies in Nigeria and Tobacco. world-leading legislation Quarterly, Vol. 30(4) 685-700 South Africa. 849 documents adopted in South Africa.

Table 2.3: Impact of Tobacco Policies that Control Advertising, Promotion and Sponsorship on Adolescents in Low and Middle Income Countries Citation Purpose Sample Study Research Findings Limitations Description Period Design 1 Mullin S, Prasad V, et al. To provide additional Three case studies Campaigns Outcome Increased awareness No such studies in (2011). “Increasing Evidence for evidence that graphic of graphic warning ran in 2009 evaluations were of the dangers of African regions the Efficacy of Tobacco Control campaigns and those mass media conducted across a smoking, greater Mass Media Communication that evoke negative campaigns in number of cessation-related Programming in Low- and emotions run over China, India, and validated thoughts and Middle-Income Countries” long periods of time Russia indicators. behaviors. Journal of Health achieve the most Communication: International influence. Perspectives, 16:sup2, 49-58

2 Nagler R, Visswanath K. (2013). A review of the Review of Literature and Although a solid Little focus on low- Implementation and research history of tobacco published media review evidence base income countries Priorities for FCTC Articles 13 marketing in high-, literature, policy underpins the FCTC dependent on tobacco and 16: Tobacco Advertising, middle, and low- and call for TAPS bans, TAPS revenue. Promotion, and Sponsorship and income countries, implementation much less is known Sales to and by Minors” identifying past reports, press about how to best Nicotine and Tobacco Research, challenges and releases, and media implement the doi:10.1093/ntr/nts331 successes. coverage. restrictions.

2.1 Literature Review Part Two

This second review is to examine the literature related the impact of tobacco control policies that ban tobacco advertising, promotion, and sponsorship and the impact of anti-tobacco mass media campaigns in Thailand and Turkey

2.1.1 Introduction

The purpose of this review is to assess the impact of Articles 12 and 13 of the World

Health Organization (WHO) Framework Convention on adult smoking in Thailand and Turkey.

Both countries have enacted laws and policies in compliance with the WHO implementation guidelines of Articles 12 and 13.

2.1.2 Background

The most effective comprehensive tobacco control programs include a component that involves the use of mass media to inform the public about the harm of tobacco use. Research shows that hard-hitting anti-tobacco mass media campaigns – via television, radio, newspapers, posters, leaflets, etc. – increases awareness of the danger of tobacco use, encourages smokers to quit or maintains abstinence in non-smokers (WHO, 2013).

The FCTC Article 12 addresses the use of mass media in tobacco control strategies by calling for countries to provide health education, communication, training and public awareness

– it states that:

Each Party shall promote and strengthen public awareness of tobacco control issues, using all available communication tools, as appropriate. Towards this end, each Party shall adopt and implement effective legislative, executive, administrative or other measures to promote:

(a) broad access to effective and comprehensive educational and public awareness programmes on the health risks including the addictive characteristics of tobacco consumption and exposure to tobacco smoke;

(b) public awareness about the health risks of tobacco consumption and exposure to

tobacco smoke, and about the benefits of the cessation of tobacco use and tobacco-free lifestyles as specified in Article 14.2;…

(f) public awareness of and access to information regarding the adverse health, economic, and environmental consequences of tobacco production and consumption. (WHO, 2003)

The use of anti-tobacco mass media campaigns is increasing; about 54% of the world’s population lives in countries that have aired at least one national anti-tobacco mass media campaign during the past two years (WHO, 2013). However, half of all countries in each income bracket – high, middle, low – have not used a national mass media campaign in the past two years to inform the public about the harms of tobacco use or to encourage smokers to quit

(WHO, 2013). The adoption of Article 12 will require further effort to encourage countries to implement its provisions.

As previously discussed, FCTC Article 13 calls for countries to implement comprehensive bans on tobacco advertising, promotion, and sponsorship – it states in part:

As a minimum, and in accordance with its constitution or constitutional principles, each Party shall: (a) prohibit all forms of tobacco advertising, promotion and sponsorship that promote a tobacco product by any means that are false, misleading or deceptive or likely to create an erroneous impression about its characteristics, health effects, hazards or emissions;

(b) require that health or other appropriate warnings or messages accompany all tobacco advertising and, as appropriate, promotion and sponsorship;

(c) restrict the use of direct or indirect incentives that encourage the purchase of tobacco products by the public;… (WHO, 2003)

Both Thailand and Turkey have responded to high smoking prevalence, especially among the male population, by establishing comprehensive tobacco control programs which include the provisions of Articles 12 and 13.

Tobacco Control Background

Thailand: According to the Global Adult Tobacco Survey conducted in 2011, 26.9% of the population smoked cigarettes – 46.4 % of males and 7.6% of females (CDC, 2013a). Thailand signed the WHO FCTC in 2004 and ratified the treaty in March 2005. Thailand has had a significant history of tobacco control activities including anti-tobacco mass media campaigns. In

1992, the Thai government enacted two major pieces of tobacco control legislation: 1) the Non- smoker’s Health Protection Act which designated totally smoke-free public places versus partially smoke free places; and 2) the Tobacco Products Control Acts which, among other initiatives, banned all types of tobacco advertising and promotion – although sponsorship was not addressed. The government included an improved enforcement strategy to address violations of the law through monthly monitoring by law enforcers.

Thailand has been cited for many of its strict tobacco control policies, however, the rate of smoking remains high among males and did not show a significant decline over the past 4 years. An examination of the impact of these long-term tobacco control policies will provide important information on how to improve their effectiveness.

Turkey: According to the 2012 Global Adult Tobacco Survey, 27.1% of the population smoked cigarettes – 41.9 % of males and 13.1 % of females (CDC, 2013a). Turkey signed the FCTC in

2004 and ratified the treaty just four months later in March 2005. In 2008, the Law on Prevention and Control of Hazards of Tobacco Products was amended to strengthen the ban on TAPS among other tobacco control initiatives. In addition a public media campaign was developed with hard-hitting ads that graphically depicted the impact of tobacco use.

As a result of aggressive action to reverse the tobacco epidemic, Turkey has been widely recognized in the global public health sector as a leader in tobacco control. However, the impact

of these recent initiatives is just taking hold and the long-term effects of these policies will require on-going monitoring and evaluation.

2.1.4 Conceptual Framework

Through the advertising of their product the tobacco industry aims to create a social norm wherein smoking is familiar, enjoyable and acceptable. Research studies have documented that

TAPS exposure increases tobacco use, hence, cigarettes continue to be one of the most heavily marketed consumer product. In the 2011, the industry spent $8.4 billion on marketing in the

U.S. alone (CDC, 2013b).

As previously discussed, it is well accepted that TAPS causes tobacco use in adolescents.

According to the research conducted by the National Cancer Institute and published in

Monograph 19: The Role of the Media in Promoting and Reducing Tobacco Use. It states: “the total weight of evidence from multiple types of studies, conducted by investigators from different disciplines and using data from many countries – demonstrate a causal relationship between tobacco advertising and promotion and increased tobacco use” (National Cancer Institute, 2008).

This conclusion applies to adults as well as adolescents. Exposure to TAPS results in increased tobacco use due to increased smoking initiation and per capita tobacco consumption in the population. However, the vast majority of studies used to make this determination were conducted in developed countries such as the US, UK, or Australia. No population-based studies from Turkey or Thailand were included in these reviews.

Monograph 19 also assessed the relationship between anti-tobacco advertising and smoking reduction. The conclusion of the studies reviewed provides evidence from controlled field experiments which suggest that “anti-tobacco mass media campaigns conducted with school- or community-based programming can be effective in curbing smoking initiation in

youth and promoting cessation in adults.” The few population-based studies of anti-tobacco advertising mass media campaigns that were found did demonstrate effectiveness in reducing smoking.

Another review of tobacco control mass media campaigns was conducted by the

Cochrane Collaboration entitled Mass Media Interventions for Smoking Cessation in Adults.

While the authors acknowledged that much of the research had been done on adolescents, they felt that enough research had been focused on adults to warrant the review. The authors’ concluded that their review of 11 campaigns provides evidence that mass media campaigns as a component of comprehensive tobacco control programs can be effective in changing smoking behavior in adults; e.g. increased quit attempts, reduced consumption, and reduced prevalence.

However, it was clear that long-term verification was difficult due to length of follow up required and the ability to compare the intensity and duration of the various campaigns. Of the

11 studies assessed, only one was conducted in a middle-income country – South Africa, the other countries were all developed, high-income countries.

More recently, research conducted in the low-income country of Bangladesh provided some encouraging information. Following a four-week anti-tobacco advertising campaign on

Bangladeshi television, 70 percent of smokers interviewed recalled the ads and of these 40 percent made an attempt to quit smoking whereas only 10% of smokers who did not recall the ad made an attempt to quit (WHO, 2013). Therefore, it is believed that hard-hitting graphic anti- tobacco campaigns are effective in reaching the public regardless of the country’s income bracket.

Further the research shows that campaigns that are sustained over longer periods of time have a lasting effect on the population; however, campaigns of only a few weeks duration can also have an impact on smoking behavior (WHO, 2013).

This review will assess what is known about the impact of TAPS policies and anti- tobacco media campaigns to reduce tobacco use specifically in the target countries of Thailand and Turkey.

2.1.5 Methods

This literature review and critique was conducted as a traditional, systematic search of multiple databases, reviews of reference lists and consultation with experts in the field. With the objective of producing a narrative review on the current state of the science on the impact of smoke-free policies in low and middle-income countries, the following databases were searched for studies: Medline; PubMED; Google Scholar, Web of Knowledge, and the Centers for Disease

Control and Prevention, Office on Smoking and Health online database.

Inclusion Criteria

Criteria required for study selection were the following:

1. Focus on research related to: i) the impact of exposure to tobacco advertising,

promotion and sponsorship in Thailand and Turkey; ii) the impact of TAPS laws

and policies in Thailand and Turkey; and ii) the impact of exposure to anti-

tobacco advertising or health education campaigns and policies in Thailand and

Turkey.

2. Include articles published or translated in the English language between 2000 and

2013 (within the past decade post FCTC);

3. Include all research designs, i.e. randomized-controlled trial, quasi-experimental,

non-randomized controlled, observational pre and post legislation, interrupted time

series, and qualitative studies, and review studies published in a peer-reviewed

journal;

4. Exclude research conducted or funded by the tobacco industry.

Key Words

Key words and terms used in this literature search were: cigarette smoking/tobacco use, tobacco behavior/attitude, Turkey, Turkish, Thailand, Thai tobacco advertising, promotion, sponsorship, marketing, tobacco policy/laws/legislation/bans/restrictions, anti-tobacco advertising, mass-media, counter-advertising, and tobacco industry.

Data Extraction

Each article was evaluated based on the inclusion criteria. Relevant articles were reviewed in depth and the following data were extracted and analyzed by country: study purpose; country of origin; sample description and size; control group; study period; outcome measures; research design; findings; and methodological limitations.

2.1.6 Literature Review Results

The initial database search produced scores of articles related to tobacco use and tobacco control policies in Thailand and Turkey. A small number of the articles reviewed were related to the impact of tobacco advertising, promotion and sponsorships or anti-tobacco campaigns on adult behavior and attitudes. Twelve studies included in the review were conducted in Turkey and 11 conducted in Thailand (see Tables 2.4 and 2.5).

The primary research design of the studies reviewed was cross-sectional surveys; including use of the nationally representative Global Adult Tobacco Survey and Global Youth

Tobacco Survey. Other surveys used were more limited in scope using convenience samples of subpopulation groups such as factory workers, government employees, and university students within a geographic area. Reviews were conducted to assess the level of tobacco control implementation and the influence of tobacco industry marketing strategies in both countries.

One study developed a simulation model called SIMSmoke and applied population data and smoking rates factored in with tobacco policies. The authors projected that tax increases and advertising bans were primarily responsible for a 25% decrease in smoking prevalence between

1991 and 2006 in Thailand (Levy 2008).

Generally it is well documented that Thailand and Turkey have implemented strong tobacco control programs and are among the global leaders in compliance with the Framework

Convention on Tobacco Control. These countries have adopted all of the Treaty’s provisions and implemented most of them according to the recommended guidelines (Bilir 2013, Sangthong

2012, Vathesatogkit 2011).

Only one study conducted in Turkey involved the evaluation of data collected over time to determine behavioral trends (Tabakoglu 2011). This study assessed cigarette brand recognition among school children before and after tobacco control laws were implemented. The results showed a significant decrease in brand recognition over time; however, the study was limited to four schools in a Turkish suburb. Exposure to tobacco advertising was confirmed as a predictor of tobacco use and was associated with increased smoking levels in Turkish males

(Erbaydar 2005, Ertas 2006, Kilic 2013, Yurt 2011)

Studies designed to determine the effect of graphic ads that warn about the dangers of smoking demonstrated that they were effective in communicating risk to smokers and affecting their attitude toward smoking (Wakefield 2013, Ozcebe 2013). The few educational

interventions that were assessed showed mixed results; however these studies were very limited in scope and population subgroups, e.g. a convenience sample of government workers or workers in one factory. (Gunes 2007, Yuksel 2005).

Two reviews of foreign tobacco company’s (British American Tobacco, Philip Morris) documents revealed the motivation behind contributions to and sponsorship of Thai community and sporting events (MacKensie, 2007; MacKensie, 2008). The authors concluded that the primary intent behind the corporate sponsorships was to promote the company and its product while staying within the legal limits of the country’s law.

The results of one study found that Thailand’s cigarette packet warning labels depicting graphic pictures of tobacco-related diseases were among contributing factors for smoker’s decision to quit (Sujirararat 2011). In a study of the differences between users of hand-rolled versus manufactured cigarettes, both groups of smokers were equally aware of the harm that tobacco caused. No studies were found that examined adult smoking prevalence associated with

TAPS exposure and anti-tobacco advertising over time to assess national behavioral trends based on the evolving tobacco control policies.

2.1.7 Discussion and Conclusion

The weight of the evidence shows that Thailand and Turkey have strong tobacco control programs and policies that, for the most part, comply with the FCTC provisions. In regards to the research topic, these countries have enforced TAPS bans and implemented anti-tobacco advertising campaigns in accordance with FCTC guidance. There are gaps in the research linking the association of tobacco behavior and attitude with exposure to TAPS and anti-tobacco advertising over time. It is important to assess how tobacco control policies affect smoking behavior and attitude in middle-income countries with high smoking prevalence. Such studies

will help to monitor the effectiveness of tobacco control policies and improve tobacco control programs.

Reduced exposure Reduced Reduced tobacco use acceptance of to TAPS tobacco use as the norm

Tobacco Policies:

-TAPS Bans Increased Reduced -Counter Tobacco Reduced tobacco use awareness of the acceptance of Messages/Warning danger of tobacco tobacco industry use messages

Tobacco Industry Reduced impact of Increased tobacco devises means of policy use skirting policies Effect Modifiers:

- Law (comprehensive/partial/weak)

- Enforcement/ Political will

- Compliance/Acceptance - Counter Tobacco Advertising - Educational Health Warnings

Figure 2.2 Conceptual Approach for Assessing Impact of TAPS Bans and Anti-Tobacco Messaging Policies

Table 2.4: Impact of Counter-Tobacco Advertising and TAPS-Related Tobacco Control Policies in Turkey Citation Purpose Sample Study Research Findings Limitations Description Period Design 1 Bilir N, Kelimeler A, Sorumlu Y. To review Turkey’s Editorial 2013 Review of Turkey met all the (2013) . “How Turkey Meets progress in Turkey’s tobacco required MPOWER MPOWER Criteria?” TAF implementing the control activities measures except for the Preventive Medicine Bulletin, MPOWER warning about the dangers 2013:Vol. 12. No. 1 measures, of tobacco and enforcement of the advertising ban.

2 CDC (2013) “Adult Awareness of To determine the Nationally 2008 - 2010 Household survey Awareness of TAPS in Cross sectional Tobacco Advertising, Promotion level of awareness representative Global Adult Turkey in 2008 was 12.4% data and Sponsorship – 14 Countries” of tobacco samples of adults in Tobacco Survey - point of sale advertising MMWR:61. advertising, 14 countries – (GATS) awareness was 2.7%. promotion and including Turkey Among the lowest in the sponsorship (TAPS) 14 countries. in 14 countries.

3 Emeri S, Bagci T, Karackoca Y, To assess the School students age 1996 Cross sectional Brand recognition for Limited study Baris, E. (1998). “Recognition of smoking behavior of 7 – 13 from 3 Just prior to study – in class cigarettes was higher than population – cigarette brand names and logos primary school primary schools in law questionnaire - for food products – linked study dated. by primary schoolchildren in children and their Ankara, Turkey. to TAPS. Ankara, Turkey” Tobacco ability to recognize N = 1093 Control: Vol. 7 brand names and logos of widely advertised cigarettes.

4 Erbaydar T. Lawrence S, Dagli E, To examine social Adolescents 13 – 17 ? Cross sectional Major predictors of Cross-sectional Hayran O, Collishaw N. (2005) determinants of years old in 15 study with smoking included close data cannot “Influence of social environment smoking among cities in Turkish standard friends who smoked; no infer causality in smoking among adolescents in adolescents schools, vocational questionnaires. knowledge of harmful Limited to a Turkey.” European Journal of attending school and training centers and effects of short-term small segment Public Health: Vol. 10 work. work places. smoking. of population. Doi:10.1093/europub/cki040

Citation Purpose Sample Study Research Findings Limitations Description Period Design 5 Ertas N. (2006) “Factors To examine Nationally 2003 Cross sectional Smoking associated with Cross sectional associated with stages of cigarette prevalence and representative school based exposure to parent, data cannot smoking among Turkish youth” determinants of sample of Turkish survey (GYTS) teacher, peers who smoke; infer causation. European Journal of Public cigarette smoking students 13- 15 cigarette promotions; and Health: Vol 17, No2 among Turkish years old perceived ease of access to youth and transition N = 15,504 cigarettes. among smoking stages.

6 Gunes G, Ilgar M, Karaoglu L. To determine the Employees in a ? 1st step – The educational program Length of (2007) “The Effectiveness of an smoking behavior factory in Malatya descriptive study; was not associated with program may Education Program on States of based on “stages of Turkey. 2nd step – quitting; however, it have been too Smoking Behavior for Workers at change” model of N = 850 experimental increased intentions and short. a Factory in Turkey.” Industrial the workers and to intervention study. preparation to quit. Health: Vol. 45 assess the Intervention is Limited to a effectiveness of an tobacco education/ small segment education program cessation program. of population. at the workplace.

7 Kilic D, Ozturk S. (2013) To examine the Nationally 2008 Household survey Factors affecting male and External social “Gender differences in cigarette potential factors representative Global Adult female smoking are influences did consumption in Turkey: Evidence associated with both sample of Turkish Tobacco Survey different. Differences also not include from the Global Adult Tobacco smoking adults over 15 years (GATS) in whether to smoke and tobacco in Survey” Health Policy: participation and the N = 9030 how much to smoke. media – ads or 2013.05.019 level of cigarette Tobacco marketing affects promotions consumption from a how much males smoke gender perspective. but not females.

8 Ozcebe H, Attila S, Bolat R, To identify some Convenience 2011 Face-to-face Participants felt that anti- Limited to a Forouz A, Kocyigit K, Ozkan O, opinions of sample of interviews using a tobacco ads motivated small segment Tasci B. (2013). “ Some Opinions government government questionnaire and smokers to quit and were of population. of Governmental Employees employees about administrative pictures of ads. effective in informing about Anti-Tobacco anti-tobacco employees in about the harmful effects Advertisements Movies on TV” advertisements. Ankara, Turkey. of tobacco. Turkish Medical Journal Vol. 14 N = 202

Citation Purpose Sample Study Research Findings Limitations Description Period Design 9 Tabakoglu E, Caglar T, Hatipoglu To evaluate the Students in grades 1996/ 1999/ Cross sectional Recognition of cigarette Limited to a O, Altiay G, Edis E, Sut N. influence of the 2-5 in 4 schools in 2006 school based brands remained high but small segment (2011). “The Influence of the Turkish anti-tobacco Edime, Turkey over questionnaire decreased significantly of population. Turkish Anti-Tobacco Law on law on children. 3 time periods. over time. Primary School Children in 1996:N = 772 Edirne” Balkan Medical Journal, 1999:N = 1157 Vol 28 2006:N = 719

10 Wakefield M. Bayly M, Durkin S, To determine if Groups of smokers 2008 Quantitative and Ads that graphically Limited to 5 Cotter T, Mullin S, Warne C. television ads in 10 LMICs qualitative design communicated the serious ads that were (2013). "Smokers’ responses to depicting the harm including Turkey. –smokers rated and harms of tobacco use were not designed or television advertisements about of tobacco use are Total N = 2399; discussed reactions more successful with targeted to each the serious harms of tobacco use: effective in LMICs. Turkey N= 240 to 5 anti-tobacco LMIC smokers than those specific pre-testing results from 10 low- to ads. with medical terms or country. middle-income countries” personal testimonies. Tobacco Control Vol. 22

11 Yuksel H, Corbett K. (2005). To evaluate youths’ High school 2001, 2003 Qualitative focus Anti-smoking messages Limited to a “Mixed messages: a qualitative thoughts about the students in groups with groups are undercut by mixed small segment study of the meanings and context norms and context Dursunbey district, of students and messages and hypocrisy in of population. of high school students’ tobacco of tobacco use in Turkey adults. parents and professionals use in Turkey.” Health Promotion Turkey Students = 52 who smoke. International: Vol. 20. No. 4 Adults = 24

12 Yurt Oncel S, Gebizlioglu O, To identify factors University students 2008 Cross sectional Among other findings Limited to a Aliev Alioglu, F. (2011) “Risk associated with at Kirikkale survey using were that the top 3 reasons small segment factors for smoking behavior increased smoking University in standard given for smoking of population. among university students.” risks among Turkey. questionnaires. initiation were for foreign Turkish Journal of Medical university students. N = 1734 commercials, foreign Science: Vol. 41. No. 6 movies, and parental smoking.

Table 2.5: Impact of Counter-Tobacco Advertising and TAPS-Related Tobacco Control Policies in Thailand Citation Purpose Sample Study Research Findings Limitations Description Period Design 1 Benjakul S, Termsirikulchai L, To examine Adults in 2009 Cross Smokers of manufactured Cross sectional Hsia J, Kengganpanich M, characteristics of Thailand – data sectional cigarettes appeared to be self-report data. Puckcharem H, Touchchai C, users of from the GATS household more knowledgeable of the Causation cannot Lohtongmongkil A, Andes L, manufactured and 2009 data collection danger of tobacco use; be inferred. Asma S. (2013). “Current RYO cigarettes and through face- however, this association manufactured cigarette smoking dual users. to-face was confounded by age and and roll-your-own cigarette interviews education. smoking in Thailand: findings from the 2009 Global Adult Tobacco Survey.” BMC Public Health. Vol. 13

2 Centers for Disease Control and To examine Adults in 2008 and Cross Thailand’s ban on almost all Cross sectional Prevention. (2010). “Differences by differences in Thailand and 2009 sectional direct and indirect self-report data Sex in Tobacco Use and Awareness tobacco use and Bangladesh – household advertising results in the of Tobacco Marketing – awareness of data from data collection lowest prevalence of aware- Bangladesh, Thailand, and marketing by sex. GATS 2008 through face- ness of TAPS Uruguay, 2009.” Morbidity and and 2009. to-face Mortality Weekly Report: May 28, surveys. 2010. Vol. 59, No. 20

3 Levy D, Benjakul S, Ross H, Using a model to Model used Data used Development Tax increases, advertising The model is Ritthiphakdee B. (2008) “The role estimate the impact Thai population from 1991 of a Thai bans were primarily complex and results of tobacco control policies in of tobacco control data, smoking and projected SimSmoke responsible for a 25% depend on data reducing smoking and deaths in a policies in Thailand rates and through 2006 Model decrease in smoking reliability, middle income nation: results from policies. and then prevalence between 1991 and assumptions and the Thailand SimSmoke simulation through 2006 compared to what it model parameters. model.” Tobacco Control: Vol. 17 2026. would have been without the Policy parameters doi:10.1136/tc.2007.022319 laws. 31,867 lives saved by subject to 2006; 319,456 lives saved by uncertainty – based 2026. on studies done in developed countries.

Citation Purpose Sample Study Research Findings Limitations Description Period Design 4 MacKensie R, Collin J. (2008). To examine the Philip Morris 2008 Iterative Philip Morris used “Philanthropy, politics and motive for a tobacco tobacco search sponsorship of community promotion: Philip Morris’ company’s company strategy. events and groups to promote “charitable contribution” in charitable documents. the industry generous Thailand.” Tobacco Control Vol. contributions in contributions were driven by 17 doi:10.1136/tc.2008.024935 Thailand. corporate self-interest.

5 MacKenzie R, Collin J, To examine how British 2003-2005 Iterative BAT used individual sports Sriwongcharoen K. (2007). BAT used sports American search sponsorships after the “Thailand – lighting up a dark sponsorship to Tobacco strategy; tobacco control law- shaped market: British American tobacco, circumvent company hermeneutic media coverage and sports sponsorship and the restrictions on documents. process. Key maximized brand awareness. circumvention of legislation.” tobacco promotion Key informants informant Adopted adversarial Journal of Epidemiological in Thailand. interviews. approach in complying with Community Health: Vol.61 the law. doi:10.1136/jech.2005.042432

6 Sangthong R, Wichaidit W, To Thailand’s Review of 1986-2009 Literature and Tobacco control measures Review does not Ketchoo, C. (2012). Current progress in evidence- based legislative relatively strong and include the past 4 situation and future challenges of implementing the tobacco control review complies with FCTC on years – dated. tobacco control policy in WHO FCTC measures in taxes, advertisement and Thailand.” Tobacco Control: Vol. provisions. Thailand warning labels 21. doi:10.1136/tc.2011.043331

7 Sujirarat D, Silpasuwan P, To determine Adult cigarette ? Longitudinal Health warnings on cigarette Conducted with a Viwatwongkasem C, whether health smokers (1-year follow packs were one external limited segment of Sirichothiratana N. (2011). warning pictures employed in 22 up) study of factor in the decision of the population. “Factors Affecting Failure to Quit affect smoking factories in smokers using smokers to quit – along with Smoking after Exposure to cessation. Thailand. stratified personal and interpersonal Pictorial Cigarette Pack Warnings 1st wave N= simple random factors. Among Employees in Thailand.” 1637 sampling and Southeast Asian Journal of 2nd wave N= Structural Tropical Medicine and Public 1300 Equation Health: Vol.42 No. 4 Modeling. 8 Vathesatogkit P, Charoenca N. A review of 20 Review of 1999-2011 Review Substantial progress made in (2011). “Tobacco control: Lessons years of tobacco documents and Thailand, however there is learnt in Thailand.” Indian Journal control experience legislation more work to be done. of Public Health: Vol 55. No. 3 in Thailand.

Citation Purpose Sample Study Research Findings Limitations Description Period Design 9 Yong H, Borland R, Hammond D, To examine the Adult smokers 2005 Cross Unprompted awareness of Self-report cross Sirirassamee B, Ritthiphakdee B, impact of tobacco in Thailand and sectional face- any tobacco marketing sectional data. Awang R, Omar M, Kin F, Zain Z, promotion in two Malaysia. to-face activities was 20% - primary Lee W, Siahpush M, Fong G. developing N =2002 location recalled was point of (2008). “Levels and correlates of countries – Thailand sale ads awareness of tobacco promotional Malaysia and N =2004 activities among adult smokers in Thailand. Malaysia Malaysia and Thailand: findings (ITC) from the International Tobacco Control Southeast Asia Survey.” Tobacco Control: Vol.17 doi:10.1136/tc.2007.021964 10 Young D, Yong H, Borland R, To describe RYO Adult smokers 2005 Cross Prevalence of RYO use in Self-report cross Ross H, Sirirassamee B, Kin F, use in Thailand and in Thailand and sectional face- Thailand – 58%. RYO sectional data. Hammond D, O’Connor R, Fong Malaysia and relate Malaysia. to-face smokers less aware of health G. (2008). “Prevalence and RYO use to International surveys warnings on packs (there are correlates of roll-your-own smokers’ Tobacco none), however equal level smoking in Thailand and Malaysia: knowledge of the Control of knowledge about harms of Findings of the ITC-South East harmfulness of Southeast Asia tobacco as manufactured Asia Survey.” Nicotine & Tobacco tobacco. Project (ITC) cigarette smokers. Research.Vol.10, No.5 N =2002 doi:10.1080/1462220802027172 Thailand N =2004 Malaysia 11 Zawahir S, Omar M, Awang R, To examine whether Adolescents 2005 Cross Antismoking education from The intensity of Yong H, Borland R, Siriassamee B, anti-smoking 13- 17 years sectional face- health professionals was not anti-smoking Fong G, Hammond D. (2013). messages and old in Thailand to-face related to perceived health education was not “Effectiveness of Antismoking education could and Malaysia surveys risk of smoking, but smoke measured – self- Media Messages and Education help to reduce from the ITC antismoking education and report measures Among Adolescents in Malaysia smoking N=1000 exposure to antismoking only. and Thailand: Findings From the susceptibility Thailand media messages was related International Tobacco Control among adolescents. N= 1008 Southeast Asia Project.” Nicotine Malaysia &Tobacco Research, Vol.15 No. 2

CHAPTER 3

THE IMPACT OF TOBACCO ADVERTISING, PROMOTION, AND SPONSORSHIP

EXPOSURE AND POLICIES ON STUDENTS’ TOBACCO-RELATED BEHAVIOR IN SIX

AFRICAN COUNTRIES1

1 English, L.M., Hsia, J., Asma, S., Lee, J., Chumbler, N. and Muilenburg, J. To be submitted to Preventive Medicine. 71

3.0 Abstract

Background: The tobacco industry sees developing countries in the continent of Africa as an opportunity to promote its product through targeted tobacco advertising, promotion and sponsorship (TAPS). Public health advocates recognize that relatively low smoking rates in most

African countries represent an opportunity to implement effective tobacco control policies that would prevent the tobacco-related epidemic that other countries are working to reverse.

Objective: To examine the impact of TAPS exposure and anti-TAPS policies on tobacco use behavior and susceptibility in adolescents in six low- and middle-income African countries.

Method: A secondary analysis of cross-sectional data from at least two rounds of the Global

Youth Tobacco Survey in the countries of Nigeria, Uganda, Tanzania, Botswana, Seychelles, and

South Africa. Several indicators of TAPS exposure were examined as correlates of smoking and smoking susceptibility outcomes. Logistic regression was used to estimate the level of association between the anti-TAPS policy and change in smoking behavior over time.

Results: Student TAPS exposure was high across all countries regardless of anti-TAPS policy -

(advertising ≥60%; promotion ≥59%; sponsorship >16%). However, students in countries with strong TAPS policies showed a decline in exposure to advertising and sponsorship over time, whereas student in countries with weak anti-TAPS policies did not. Smoking prevalence increased over time in countries with weak anti-TAPS policies (AOR 1.64, p=.008) but declined in countries with strong anti-TAPS policies (AOR 0.88, p =.001). No change in smoking prevalence over time was observed in countries without any TAPS policies. No change in smoking susceptibility was observed both in countries with strong anti-TAPS policies and those with no TAPS policies. However there was a significant increase over time in susceptibility among students in countries with weak anti-TAPS policies (AOR 1.51, p=.001).

Conclusion: Enforcement of strong anti-TAPS policies can be a viable part of an effective tobacco control program in African countries. Such regulations, if effectively implemented, can help to reduce TAPS exposure in adolescents and affect smoking behavior.

Keywords: Tobacco use; Smoking; Tobacco Advertising; Promotion Sponsorship; Tobacco

Policies; Youth; Surveillance; Africa.

3.1 Introduction

Tobacco use is the leading cause of preventable death in the world. By 2030 it is projected that tobacco use will kill over 8 million people per year; with 80 percent of these deaths occurring in low and middle-income countries (WHO, 2013). This represents a striking reversal of the epidemic due to the decline of smoking in developed countries and the uptake of tobacco use in low and middle income countries (LMICs). Cigarette smoking is the most common form of tobacco use worldwide. It is well documented that smoking initiation typically begins in adolescence or earlier (U.S. Department of Health & Human Services, 2012 SGR). The

U.S. Surgeon General’s Report “Preventing Tobacco Use Among Youth and Young Adults” determined that “there is a causal relationship between the advertising and promotional efforts of tobacco companies and the initiation and progression of tobacco use among young people” (U.S.

Department of Health & Human Services, 2012 SGR). In addition, several longitudinal studies have demonstrated that nonsmoking adolescents who were more aware of or receptive to tobacco advertising were more likely to have experimented with cigarettes or become smokers (Lovato,

2011).

The Tobacco Industry uses both direct and indirect strategies for tobacco advertising, promotion and sponsorship (TAPS) with the aim, or likely effect of promoting a tobacco product or tobacco use (WHO, 2003). The WHO defines advertising and promotion as any form of commercial communication, recommendation or action on behalf of a tobacco product; and sponsorship as any form of industry contribution to an event, activity or individual (WHO,

2013c). As countries have increasingly started to enact laws banning TAPS, the industry’s marketing tactics have become less overt, switching instead to indirect strategies such as brand- marking which is the use of brand colors or designs, logos or trademarks in entertainment

venues, retail outlets, and on vehicles or equipment; point-of-sale displays at retail establishments; brand stretching where non-tobacco items share the brand name; product placement in entertainment media settings; virtual advertising using word-of-mouth peer group recommendations (at sponsored events, mobile phone messages, and Internet communications); and corporate social responsibility initiatives involving donations to charitable activities, educational programs and community projects. (See Appendix C for examples of TAPS in

African countries)

The World Health Organization’s (WHO) Framework Convention on Tobacco Control

(FCTC) addresses the global tobacco epidemic through its comprehensive evidence-based provisions designed to reduce the supply of and demand for tobacco in countries and thereby prevent tobacco-related death and disease. Article 13 of the FCTC addresses the recommendations and guidelines that will help countries avoid the effect of tobacco advertising, promotion and sponsorship by implementing comprehensive bans on direct and indirect TAPS.

Bans on advertising, promotion and sponsorship are among the most effective ways to reduce tobacco consumption. Countries that have introduced a comprehensive or total TAPS ban show an average of 7% reduction in tobacco consumption across their population (WHO Report,

2013). Partial bans are much less effective in reducing consumption as the industry finds alternate marketing methods through loopholes in weaker regulations. The majority of research on the impact of TAPS bans has been conducted in developed countries that were among the first to adopt effective TAPS regulations. According to the WHO 2013 Global Tobacco Control

Progress Report on FCTC Implementation only 24 countries reported that they had adopted a comprehensive ban on all tobacco advertising, promotion and sponsorship; this represents fewer than 10% of the world’s population.

In an effort to replace customers and maintain or increase tobacco sales and profits, the industry now focuses its TAPS strategies on developing countries including the continent of

Africa. This region represents a growth opportunity for the industry as many African countries have low smoking rates and young, growing populations with increasing disposable incomes.

Multinational tobacco companies have set up regional headquarters in African nations and engaged in aggressive marketing tactics that threaten to initiate an epidemic of tobacco-related morbidity and mortality that the region can ill afford. Public health proponents recognize that the relatively low rates of smoking in African countries represent an opportunity to implement effective tobacco control policies sooner rather than later, which would prevent the tobacco- related epidemic that other LMICs are working to reverse.

Forty-one of 46 countries in the WHO African region have signed on as parties to the

FCTC. Some countries have made notable progress in adopting effective tobacco control policies. However, progress in comprehensively banning TAPS in Africa has been slow. Five countries have comprehensive bans that cover all forms of direct and indirect advertising.

Another 22 countries have limited bans only on direct tobacco advertising on national television, radio and print media. More research relevant to this region is required to enhance the work of tobacco advocates in achieving the effective adoption of evidence-based tobacco control policies including comprehensive TAPS bans.

A review of the existing literature on the impact of tobacco advertising, promotion and sponsorship in Africa suggests that there is an association between TAPS and tobacco behavior in African adolescents. Studies reviewed also corroborate previous findings that show a positive correlation between familial or peer relationships and tobacco consumption (Doku, 2012). Other studies suggest that factors, such as economic conditions and cultural values, may have a

significant impact on smoking prevalence in adolescents (Doku, 2010). However, there are gaps in the research specifically related to the impact of TAPS bans on smoking in adolescents in

Africa. Additional research is needed to evaluate the impact of tobacco control policies on adolescent smoking behaviors and attitudes in African countries over time. This is required to assess the effectiveness of these policies and make necessary modifications to enhance their impact.

This paper will examine the impact of TAPS exposure and policies that ban TAPS on tobacco use behavior and susceptibility in adolescents in six low and middle income African countries. The expectation is that over time countries that have adopted and achieved compliance with strong TAPS policies should show a decrease in smoking behavior and susceptibility.

Conversely, weaker policies with less compliance should result in no change or an increase in smoking behavior and susceptibility over time.

3.2 Background

Seven African countries – Nigeria, Uganda, Botswana, Tanzania, Kenya, Seychelles, and

South Africa – initially met the criteria for inclusion in the study. The criteria were: low- or middle-income as defined by the United Nations; FCTC ratification; access to two or more rounds of youth tobacco use data (with at least one round of data collected after FCTC ratification); anti-TAPS policy assessed by WHO as either none, partial (weak), or comprehensive (strong) (See Table 1).

Although Kenya met these criteria, the second round of GYTS data was collected in 2007 which was the same year the government adopted comprehensive anti-TAPS legislation; it was therefore assumed that inadequate time had lapsed to observe an effect of their new policies.

Therefore, Kenya was not included in data analyses and the remaining six countries were the focus of this research study.

Table 1: Countries by TAPS Policy Classification Tobacco Advertising, Promotion & Country GYTS Survey FCTC Anti-TAPS Sponsorship (TAPS) Policy Rounds Ratified Law passed

No Policy/No Compliance Nigeria ‘00, ‘08 2005 None No national TAPS regulation Uganda ‘02, ‘07 2007 None

Weak Policy/Weak Compliance Botswana ‘01, ‘08 2005 1999/2004* Partial TAPS ban WHO compliance score = 3-7 Tanzania ‘03, ‘08 2007 2003

Kenya** ’01, ‘07 2004 2007 Strong Policy/Strong Compliance Comprehensive TAPS ban Seychelles ‘02, ‘07 2003 1998/2009* WHO compliance score = 8-10 South

‘99, ‘02, ’07, ‘11 2005 1999 Africa * Law amended **Kenya not included in data analyses due to timing of GYTS data collection and adoption of anti-TAPS law

The countries’ tobacco policy categories are based on TAPS measures developed by the

WHO and published in WHO Global Tobacco Control Reports of 2008, 2009, 2011, and 2013.

In these reports, standardized methods were used to measure, rate and score countries’ progress in adopting and complying with key provisions of the Treaty (WHO Report, 2008; WHO Report,

2009; WHO Report, 2011; WHO Report, 2013). According to WHO, tobacco control regulations that fail to ban advertising on national television, radio and print media are classified as non-existent policies; weak policies are those which ban only direct advertising on national, television, radio and print media; and strong or comprehensive policies ban all direct advertising and most forms of indirect tobacco promotions and sponsorships. Compliance is measured by how strictly the law is enforced by the government and adhered to by the tobacco industry – each

country receives a compliance score, from the WHO, on a scale of zero to ten. (See Appendix

Table A1 for additional details)

3.3 Country TAPS Policy and Tobacco Use

A profile depicting tobacco-related statistics for each country is presented in Table 2; followed by descriptions of each country’s tobacco control status including anti- TAPS policy adoption and implementation.

Table 2: Tobacco Profile by Country

Income Population Adult Smoking Student Smoking FCTC Level (millions) Prevalence (%) Prevalence (%) Ratified ♂ ♀ No TAPS NIGERIA Middle 162 7.3 0.4 2.6 – 6.2* 2005 Policy UGANDA Low 35 15.0 1.4 4.8 2007

Weak BOTSWANA Middle 2 20.1 1.5 16.3 2005 TAPS Policy TANZANIA Low 46 17.4 1.2 1.7-3.6* 2007

Strong TAPS SEYCHELLES Middle 0.9 21.0 2.0 21.5 2003 Policy S. AFRICA Middle 51 21.2 7.2 13.6 2005 *Regional Range Data sources: CDC Global Surveillance System - GYTS, GATS WHO Reports

3.3.1 Countries with No TAPS Policies

Nigeria: In 2005 Nigeria passed a law that banned indoor smoking in certain public facilities, however, there is no national legislation that prohibits TAPS. In 2009, a National Tobacco

Control bill which included a ban on tobacco advertising was introduced in the Nigerian Senate.

The bill passed the Senate in 2011; however, it remains unsigned by the President despite numerous calls from tobacco control advocates for its ratification. Industry forecasters claimed

that in 2011 the tobacco market registered the strongest value growth ever and predicted a continued slow rise in smoking prevalence (Euromonitor International, 2013).

Uganda: Uganda is a key tobacco producer for British American Tobacco and is home to the company’s regional headquarters. The government passed a smoke-free law that applies to health care facilities, educational and governmental offices. However, there are no policies that address

TAPS and advertising is becoming increasingly widespread. British American Tobacco traditionally sponsors sports-related events in Uganda and within the past decade has responded to increasing criticism for its aggressive marketing tactics by reducing direct advertising and sponsorship of athletic events (Tobacco Control, 2000). However, there are recent reports of significant escalations in indirect marketing such as street party sponsorships and point-of-sale promotions which attract youth. (Centre for Tobacco Control in Africa, 2013)

3.3.2 Countries with Partial TAPS Policies/Weak Compliance

Botswana: In 1999, the government of Botswana enacted the Control of Smoking Act which prohibited the sale of tobacco to youth under 16 and regulated smoking and smoke-free environments. In 2004 the law was amended to include warning labels on cigarette packs and strengthen the existing advertising ban. Tobacco advertising was banned on national TV and radio, local magazines and newspapers, billboards and outdoor spaces as well as at points-of- sale. The Act further banned the appearance of products in TV shows or movies. However, indirect marketing such as free distribution, promotional discounts and sponsored community events are not addressed by the current version of the legislation.

Although Botswana has made attempts to implement national tobacco control objectives, it has been documented that enforcement of the Control of Smoking Act has been lenient and

ineffective (Mbongwe, 2004). The tobacco industry continues to violate provisions of the law and widely uses indirect methods to market cigarettes.

Tanzania: The United Republic of Tanzania relies on tobacco cultivation and export as key components of its economic growth plan. Tobacco production has increased 110% over the past decade making Tanzania 14th in the global ranking of tobacco producers (Drope, 2011). In

2003, the government enacted the Tobacco Products (Regulation) Act which bans direct advertising on national and international TV, radio, newspapers and magazines, outdoor spaces and the internet, however, no ban was placed on point-of-sale advertising. The law extends the ban to distribution of free cigarettes and product brand placement on TV or movies. Despite the intent of the law, it was widely reported that the tobacco industry continues to actively market cigarettes by taking advantage of loopholes in the law and weak enforcement of it provisions

(Tanzanian Tobacco Control Forum, 2011).

3.3.3 Strong TAPS Policies/Strong Compliance

Seychelles: As the first African country to ratify the FCTC, Seychelles continued to strengthen their tobacco control program which has been active since the 1980s. Tobacco prevention initiatives include public health education and prohibition of tobacco advertising and increased tobacco taxes. The 2009 Seychelles Tobacco Control Act further strengthened the existing policies and extended the ban on tobacco advertising to include restrictions on indirect tobacco promotion and sponsorship. A National Tobacco Control Board was created to aid in enforcing the law and was authorized to address offenses and levy penalties for violations (Viswanathan,

2011).

South Africa: South Africa has achieved significant advances in tobacco control over the past decade due to a strong public health advocacy community and effective tobacco prevention

policies implemented by the government. However, smoking prevalence remains comparatively high within the region. Four major tobacco control legislations have been enacted since the 1993

Tobacco Act which prescribed health warning on advertisements. The Act was amended in 1999 and banned all tobacco advertising and sponsorships; restricted points-of-sale advertising to listing availability and price only. Further amendments later restricted the size of point-of-sale notices and phased-out existing contractual sponsorships and advertising obligations. The most recent amendment in 2011 banned virtual advertising of tobacco products. South Africa is recognized as having one of the world’s most robust and comprehensive laws that controls tobacco manufacturing, export, smoking, marketing, and taxation (Drope, 2011). Taxes increased the price of cigarettes by 157% between 1992 and 2008 and tobacco consumption decreased by 35%. The Ministry of Health was given the authority to make additional regulations as well as enforce policies and penalties in implementing the law. Industry forecasters recently predicted a sharp downturn in tobacco value in South Africa due to “a stricter operating environment” (Euromonitor International, 2013).

3.4 Methods

This study involved secondary analysis of publicly available data from the Global Youth

Tobacco Survey (GYTS) for six African countries. The GYTS, the largest ongoing global public health surveillance system, was developed in 1999 through the partnership of the World Health

Organization and the U.S. Centers for Disease Control and Prevention. Since 1999, 180 countries and WHO states have completed the GYTS at least once and many having done so multiple times. The GYTS is a school-based, self-administered survey of students in grades 8-10

(typically 13-15 years old) which provides national, state or provincial data on tobacco use initiation, prevalence, knowledge, attitudes, susceptibility; exposure to tobacco advertising,

promotion and sponsorships; secondhand smoke; and desire to quit. Standardized methods are used to construct sampling frames, select schools and classrooms, prepare the questionnaire, conduct field protocols, and process data.

The surveys are designed to produce nationally representative estimates, by gender, with a minimum student sample size of 1,500 from a minimum of 20 schools. GYTS is a two-stage sample design; first schools are selected proportional to enrollment size, then classrooms are randomly selected within selected schools. The sample design is adjusted for potential nonresponse and ineligibility at each stage (80% school participation and student attendance rates). To account for sample selection, non-response and post-stratification of the sample population, the survey data is weighted by taking into account the specific sampling frame and weight associated with each of the questionnaires.

3.4.1 Measures

Current cigarette smoking and susceptibility to smoking were assessed as outcome variables. Adolescents were defined as current smokers if they reported smoking one or more days in the past month. Adolescents who reported never trying a cigarette were considered to be susceptible to smoking if they did not answer affirmatively that they would not smoke within the next 12 months or would not accept a cigarette offered by a friend.

Several indicators of TAPS exposure were examined as correlates of smoking outcomes; exposure was measured based on responses to the questions listed in Table 3. The responses were dichotomized to produce any level of exposure versus no exposure as preliminary analyses did not show significant differences between the levels of exposure (i.e. a lot or some).

The following variables: sex, age, attitude towards smoking and smokers, and had parents and/or close friends who smoked were examined as potential confounders of the relationship

Table 3: GYTS Measures, Questions, and Recodes Variable Question Responses Recode Gender What is your sex Male 1= Male Female 2 =Female Age How old are you? >11 to 18+ 1= 13 years 2 =14 years 3 = 15 years Ever Smoked Have you ever tried or experimented with cigarette smoking, Tried smoking 1 = Yes even one or two puffs? 2 = No Current During the past 30 days, on how many days did you smoke Smoked ≥1 day within last 1 = Yes Smoker cigarettes? 30 days 2 = No Susceptibly to -If one of your best friends offered you a cigarette, would you 1= Definitely not 1 = Susceptible (2-4) smoking smoke it? 2= Probably not 2 =Non-susceptible (1) -At any time during the next 12 months do you think you will 3=Probably yes smoke a cigarette? 4=Definitely yes TAPS Advertising -During the past 30 days, how many cigarette advertisements 1 = a lot 1 = Exposed (1,2) have you seen on billboards? 2 = sometimes 2 = Not Exposed (3) -During the past 30 days, how many cigarette advertisements or 3 = none promotions have you seen in newspapers or magazines? Promotion -Do you have something (t-shirt, pen, backpack, etc.) with a 1= Yes 1= Yes cigarette brand logo on it? 2= No 2= No -Has a cigarette representative ever offered you a free cigarette? Sponsorship -During the past 30 days, when you watched TV sports events or 1= never watch TV, or 1 = Exposed (2,3) other programs how often did you see cigarette brand names? don’t go to events 2 = Not Exposed (1,4) -When you go to sports or community events, how often do you 2 = a lot see cigarette advertisements? 3 = sometimes 4 = never Attitude -Social norm -Do you think boys who smoke cigarettes have more or less 1 = more 1 = Positive (1,3) friends? 2 = less 2= Negative (2) -Do you think girls who smoke cigarettes have more or less 3 = same friends? -Does smoking cigarettes help people feel more or less comfortable at celebrations, parties, or in other social gatherings?

-Attractiveness -Smoking cigarettes makes boys look more/less attractive? 1=more/ 2=less/ 3=same 1 = Positive (1,3)

-Smoking cigarettes makes girls look more or less attractive? 2= Negative (2)

1-4 = Positive adjectives 1 = Positive (1-4) -What do you think of a man you see smoking? 5-8 = Negative adjectives 2= Negative (5-8) -What do you think of a woman you see smoking? Influence -Do your parents smoke? 1 = None; 2 = Both 1 = Yes (2 - 4) 3 = Father 4 = Mother 2 = No (1, 5) 5 = Don’t know -Do any of your closest friends smoke? 1 = None; 2 = Some 1 = Yes (2 - 4) 3 = Most 4 = All 2 = No (1) Smoking in -When you watch TV, videos, or movies, how often do you see 1= never watch TV, etc. 1 = Exposed (2,3) media actors smoking? 2 = a lot 2 = Not Exposed (1,4) 3 = sometimes 4 = never

between TAPS exposure and smoking behaviors. Exposure to parents or close friends who smoked was dichotomized to reflect having a parent or friend who smoked versus no parent or friend who smoked. To allow for cross-country comparisons, students who were not between the targeted ages of 13 and 15 were excluded from the analyses.

3.4.2 Statistical Analysis

The country data files for each survey round were downloaded from CDC’s website and converted to Statistical Analysis Software (SAS) version 9.3 for analysis. All the analyses were weighted to account for the complex sampling method used in the GYTS. Frequency counts were computed for the respondent’s demographic variables – age and sex. Frequencies were analyzed for the distribution of respondents by smoking and susceptibility status for each variable listed in Table 3 – TAPS exposure, attitude, having peers or parents who smoked.

Differences were compared between survey rounds for each country - using round one as the referent year to determine change in selected characteristics between the two data collection time periods. Four rounds of data were collected in South Africa, therefore the referent year one, was compared to round four data. The results for all four data rounds are presented to show the trend in South Africa over time. The standard errors of the estimates were computed and used to produce 95% confidence intervals which are shown as upper and lower bounds. Comparisons were deemed as statistically significant when 95% confidence intervals did not overlap.

To evaluate the impact of change in smoking behaviors and TAPS exposure over time by

TAPS policy, logistic regression analysis was used to determine odds ratios and 95% confidence intervals for smoking prevalence and susceptibility. Three logistic regression models were fitted with independent variables as follows: a) year; b) social influence variables i.e. parents or friends smoked; and c) TAPS exposure variables. The models tested the association between smoking

behaviors and anti-TAPS policy across data collection rounds adjusted for risk factor variables - social influence and TAPS exposure. All tests were considered to be significant at the 0.05 level.

As a result of interaction, the models tested the relationships stratified by anti-TAPS policy strength.

3.5 Results

3.5.1 Exposure to Tobacco Advertising Promotion and Sponsorships (TAPS)

The prevalence of exposure to tobacco advertising, promotion and sponsorship by country is presented in Figures 1 through 3. Substantial proportions of students in all countries reported noticing advertising through print ads and billboards; the most recent round of data indicated a range from 60% in Uganda to 75% in Tanzania. Almost 60% of students observed tobacco sponsorships such as recognizing specific brand names while watching sports or TV programs or seeing promotional materials while attending a community or social event – this ranged from

59% in Uganda to 77% in Seychelles. Exposure to tobacco promotions, which includes students owning items with tobacco brand logos or receiving offers of free cigarettes, was comparatively lower across countries – ranging from 16% in Tanzania to 24% in Nigeria.

Although countries with comprehensive strong anti-TAPS bans showed high levels of TAPS exposure; exposure declined over the time period between data collection rounds. Students’

TAPS exposure in South Africa decreased significantly across the four rounds of data collection.

In 1999 exposure to advertising and sponsorships was reported at 86% and 82% then decreased in 2011 to 72% and 71%, respectively. Seychelles also reported significant decreases in exposure to tobacco sponsorships across the two rounds of data collection – going from 88% to 77%.

Countries with weak anti-TAPS policy also had high levels of TAPS exposure; however the change in exposure over time showed mixed results. Tanzania and Botswana showed

significant increases in student exposure to tobacco sponsorships between the data rounds– ranging from 63.3% and 67.2% climbing to 68.8% and 72.8%, respectively. Both countries, however, showed no change in advertising exposure and significant decreases over time in exposure to tobacco promotion.

Countries with no TAPS policies also had comparably high levels of TAPS exposures.

Over time, however, no significant change TAPS exposure was observed in these countries except for a decrease in tobacco promotion exposure in Nigeria. Despite the various policies across these countries, levels of TAPS exposure among 13 to 15 year old school students remained relatively high across all six countries.

3.5.2 Smoking in media

Observation of smoking in the media (i.e. actors smoking on television, movies, or videos) is an area for concern as it is not typically addressed in anti-TAPS regulations; however it has been linked smoking initiation and positive attitude towards smoking among adolescents (Health and

Human Services: SGR, 2012).

According to the most recent data round for each country, over 70% of students reported seeing actors smoking in movies or on TV; levels ranged from 71% - 92% (See Figure 4). The prevalence of students who reported seeing a lot of smoking in movies or television increased significantly across GYTS rounds for Botswana (up 23%) and Tanzania (up 30%). Conversely,

South Africa was the only country where the prevalence of students who reported seeing a lot of smoking in movies or on television decreased significantly by 10.5% between 1999 and 2011.

3.5.3 Smoking Behavior

The GYTS data for students’ smoking behavior, including current smokers, ‘ever tried’ and susceptible to smoking are displayed by country in Figures 5-7. An assessment of the most

recent round of GYTS data for each country shows the prevalence of current smoking among students ranged from 2.7% in Tanzania (2008) to 21.5% in Seychelles (2007).

When smoking prevalence was compared across countries with anti-TAPS policies, notable differences in prevalence were observed based on income. Middle income countries with existing anti-TAPS policies include South Africa, Botswana and Seychelles, in these countries current smoking among students was 13.6% 14.3%, and 21.5% respectively. In contrast,

Tanzania, the only low income country with existing anti-TAPS policies, had a relatively low smoking prevalence of 2.7%. The two countries with no existing anti-TAPS policies, Nigeria and Uganda both had comparatively low prevalence at 4.1% and 4.8% respectively.

Botswana, a middle income country with weak anti-TAPS policies, is the only country where the prevalence of current smokers increased significantly between GYTS rounds. The prevalence of student smokers was 8.3% in 2001 and rose to 16.3% in 2008 – an increase of 96 percent. (p =.001). The prevalence of current smokers decreased significantly in South Africa – a middle income country with strong, comprehensive anti-TAPS policies. The prevalence of student smoking in South Africa dropped from 17.6% to 12.7% between 1999 and 2011 – a 28% decline in just over a decade.

In all countries, excluding Botswana, students experimented with cigarettes (ever tried smoking) at over double the rate of students who currently smoked. Students who ever smoked ranged from 10.2% in Tanzania to 48.4% in Seychelles. The prevalence of South African students who reported ever smoking declined significantly by 29% between 1999 and 2011.

3.5.4 Demographics of Current Smokers

Across all countries, the prevalence of current smoking among students was higher in boys than in girls (see Figure 8). Current smoking among males ranged from 3% to 23% versus

a range of 2% to 20% among females. However in many countries the differences between male and female students were not significant. Among the three age groups included in the study, 15 year old students smoked at significantly higher rates than 14 and 13 year olds in South Africa and Seychelles. In the remaining countries student smokers did not vary significantly by age.

3.5.5 Susceptibility

The prevalence of students who were susceptible to smoking ranged from 6.1% in

Tanzania to 39.1% in Seychelles in the most recent GYTS data rounds. All countries showed a downward trend in susceptibility except Uganda and Botswana which had a substantial increase of 117% in susceptibility between GYTS rounds. Significant decreases in susceptibility were reported over time in Nigeria from 29.4% to 18.2 % - a 38% decrease between 2001 and 2008; and in South Africa from 38.1% to 29.9 % between 1991 and 2011 – a 22% decrease.

3.5.6 Attitude towards Smoking and Smokers

The most recent country data shows no relationship between TAPS policy classification and attitudes towards smoking. It appears that the majority of students across countries, with few exceptions, have neutral attitudes towards smoking and smokers, they did not feeling that smoking or being a smoker provided more or fewer advantages. Most notably, however,

Botswana’s students had positive attitudes towards smokers at the highest rates (20% favorable attitude toward male smokers, 23% toward female smokers).

Over time trends in positive attitudes toward smokers increased significantly in Uganda with a 100% increase in positive attitude to male smokers; Botswana had a 31% increase in positive attitude to males and 122% to female smokers; and Tanzania showed a 31% increase in positive attitude to males and 33% to female smokers. In contrast, South African students showed a 39%

decrease in those with a positive attitude toward male smokers and a 29% decrease for female smokers.

3.5.7 Peer Influence

In all countries students reported having close friends who smoke at a much higher rate that they smoked – the prevalence of students with close friends who smoked ranged from 14.3% in Tanzania to 56.4% in Seychelles. While only 2.7% of Tanzanian students were current smokers, 14.3% of students reported having a close friend who smoked. In Seychelles, 21.5% of students reported as current smokers compared to 56.4% who reported close friends who smoked.

All countries showed a decrease in prevalence of friends who smoke across the rounds of data collection except Botswana (see Figure 9). South Africa reported a significant decrease of

32% in students with close friends who smoked between 1999 and 2011

3.5.8 Parental Influence

The prevalence of parental smoking across the countries correlated with country income level. Among low income countries the prevalence ranged from 10.9% in Uganda to 11% in

Tanzania; while parental smoking rates in middle income countries ranged from17.4% in Nigeria to 30.5% in Seychelles (see Figure 10).

Significant decreases in parental smoking prevalence were reported across the four rounds of data collection in South Africa; declining from 43.3% in 1999 to 29.9% in 2011. The prevalence of Nigerian parents who smoked increased from 14.1% to 17.4% between 2001 and 2008.

Observed a lot Observed some

100

0 r 1 r 2 r 1 r 2 r 1 r 2 r 1 r 2 r 1 r 2 r 1 r 2 r 3 r 4 Nigeria Uganda Botswana Tanzania Seychelles South Africa

No TAPS Policy Partial/Weak TAPS Policy Comprehensive/Strong TAPS Policy Figure 1: Observed advertising in media by GYTS round by country

0 r 1 r 2 r 1 r 2 r 1 r 2 r 1 r 2 r 1 r 2 r 1 r 2 r 3 r 4 Nigeria Uganda Botswana Tanzania Seychelles South Africa

No TAPS Policy Partial/Weak TAPS Policy Comprehensive/Strong TAPS Policy Figure 2: Noticed tobacco promotion by GYTS round by country

Observed a lot Observed some

100

0 r 1 r 2 r 1 r 2 r 1 r 2 r 1 r 2 r 1 r 2 r 1 r 2 r 3 r 4 Nigeria Uganda Botswana Tanzania Seychelles South Africa

No TAPS Policy Partial/Weak TAPS Policy Comprehensive/Strong TAPS Policy

Figure 3: Observed tobacco sponsorship by GYTS round by country

Observed a lot Observed some

100

0 r 1 r 2 r 1 r 2 r 1 r 2 r 1 r 2 r 1 r 2 r 1 r 2 r 3 r 4 Nigeria Uganda Botswana Tanzania Seychelles South Africa

No TAPS Policy Partial/Weak TAPS Policy Comprehensive/Strong TAPS Policy Figure 4: Observed smoking in the media

Round 1 Round 2 Round 3 Round 4 60

0 Nigeria Uganda Botswana Tanzania Seychelles S. Africa

No TAPS Policy Comprehensive/Strong TAPS Policy Partial/Weak TAPS Policy Figure 5: Current smokers by GYTS round by country

Round 1 Round 2 Round 3 Round 4 60

0 Nigeria Uganda Botswana Tanzania Seychelles S. Africa

No TAPS Policy Partial/Weak TAPS Policy Comprehensive/Strong TAPS Policy

Figure 6: Ever tried smoking by GYTS round by country

Round1 Round 2 Round 3 Round 4

0 Nigeria Uganda Botswana Tanzania Seychelles South Africa

No TAPS Policy Comprehensive/Strong TAPS Policy Partial/Weak TAPS Policy Figure 7: Susceptible to smoking by GYTS round by country

Male Smoker Female Smoker

0 r 1 r 2 r 1 r 2 r 1 r 2 r 1 r 2 r 1 r 2 r 1 r 2 r 3 r 4 Nigeria Uganda Botswana Tanzania Seychelles South Africa

Comprehensive/Strong TAPS Policy No TAPS Policy Partial/Weak TAPS Policy

Figure 8: Current smokers by GYTS round by gender and country

Round 1 Round 2 Round 3 Round 4 70

0 Nigeria Uganda Botswana Tanzania Seychelles S. Africa

No TAPS Policy Partial/Weak TAPS Policy Comprehensive/Strong TAPS Policy

Figure 9: Close friends who smoke by GYTS round by country

Round 1 Round 2 Round 3 Round 4 60

0 Nigeria Uganda Botswana Tanzania Seychelles S. Africa

No TAPS Policy Comprehensive/Strong TAPS Policy Partial/Weak TAPS Policy Figure 10: Parents smoke by GYTS round by country

Table 4: Differences in Current Smoking by Demographic Subgroups, Ever-tried and Susceptible to Smoking by Country and TAPS Policy Current Smoking Ever Tried Susceptible Total Male Female 13 years 14 years 15 years Smoking to smoking % 7.02 7.74 3.33 11.80 5.50 6.28 14.64 29.44 Round 1 CI (4.1, 10.0) (3.7, 11.8) (1.6, 5.1) (4.7, 18.9) (2.6, 8.4) (3.2, 9.4) (9.3, 20.0) (24.8, 34.0) 2000 n 815 319 420 151 313 351 860 906 NIGERIA % 4.06 6.78 1.19 5.57 4.31 2.77 13.38 18.24 No TAPS Policy Round 2 CI (0.4, 7.8) (0.7, 12.8) (-0.6, 3.0) (-1.3, 12.4) (-1.6, 10.2) (-0.2, 5.6) (8.0, 18.7) (9.8, 26.7) 2008 n 310 131 162 70 133 107 322 330 ∆ -0.420 -0.124 -0.643 -0.500 -0.216 -0.559 -0.086 -0.380 P .279 .802 .191 .266 .742 .156 .746 .044 % 5.46 6.64 3.99 4.19 5.57 5.98 15.60 12.49 Round 1 CI (4.1, 6.9) (5.1,8.2) (2.5, 5.4) (2.3,6.1) (3.7, 7.5) (4.2, 7.7) (13.1, 18.1) (10.8, 14.2) 2002 n 2412 1113 1243 553 858 1001 2459 2550 UGANDA % 4.81 5.00 4.72 5.37 4.63 4.66 10.88 15.75 Round 2 No TAPS Policy CI (3.0, 6.7) (2.9, 7.1) (1.9, 7.5) (2.0, 8.8) (1.5, 7.8) (2.0, 5.3) (7.6, 14.2) (11.1, 20.4) 2007 n 1909 765 1140 478 702 729 1926 2026 ∆ -0.119 -0.247 0.183 0.282 -0.169 -0.221 -0.303 0.261 P .594 .209 .636 .522 .640 .443 .052 .199 % 8.31 10.36 6.47 7.33 6.75 9.65 12.17 14.52 Round 1 CI (6.3, 10.3) (7.5, 13.2) (4.3, 8.6) (0.8, 13.8) (3.7, 9.8) (7.3, 12.0) (9.3,15.0) (11.8, 17.3 2001 n 1073 459 611 96 422 555 1070 1072 BOTSWANA % 16.27 18.08 10.85 15.50 14.40 13.17 15.47 31.54 Round 2 Weak TAPS CI (13.0, 20.5) (13.9, 23.0) (7.4, 14.3) (9.1, 21.9) (11.4, 17.4) (9.2, 17.2) (12.0, 19.0) (27.3, 35.8) 2008 Policy n 1605 655 926 442 869 526 1599 1605 ∆ 0.958 0.745 0.677 1.115 1.133 0.365 0.271 1.172 P .001 .004 .025 .113 .002 .117 .143 <.0001 % 2.12 3.44 1.08 1.92 2.15 2.34 8.10 7.40 Round 1 CI (1.6, 2.7) (2.3, 4.6) (0.5, 1.7) (1.1, 2.7) (1.4, 2.8) (1.1, 3.5) (6.8, 9.4) (6.3, 8.5) 2003 n 3588 1492 2041 1264 1313 1011 3643 3777 % 2.72 3.48 1.97 2.23 3.21 2.58 10.24 6.10 TANZANIA Round 2 CI (1.1, 4.3) (1.8, 5.2) (0.1, 3.8) (0.8, 3.7) (1.4, 5.0) (0.5, 4.7) (7.2, 13.3) (3.3, 8.9) Weak TAPS 2008 Policy n 3446 1496 1935 1269 1388 789 3501 3395 ∆ 0.283 0.012 0.824 0.161 0.493 0.103 0.264 -0.176 P .455 .969 .276 .701 .226 .846 .186 .424

Table 4 continued Current Smoking Ever Tried Susceptible Total Male Female 13 years 14 years 15 years Smoking to smoking % 26.78 29.89 23.92 22.83 23.60 33.08 50.60 42.09 Round 1 CI (21.8, 31,8) (23.0, 36.8) (18.4, 29.4) (16.3, 29.4) (17.1, 30.1) (24.0, 42.1) (46.2, 55.0) (36.7, 47.5) 2002 n 865 390 461 254 330 281 905 941 SEYCHELLES % 21.50 23.18 20.01 15.32 22.26 27.23 48.39 39.13 Strong TAPS Round 2 CI (14.6, 28.4) (16.8, 29.6) (14.5, 25.5) (9.17, 21.5) (13.8, 30.7) (21.6, 32.8 (42.5, 54.3) (34.6, 43.7) Policy 2007 n 783 359 416 260 317 206 824 843 ∆ -0.197 -0.224 -0.163 -0.329 -0.057 -0.177 -0.001 -0.070 P .153 . 159 . 328 .090 806 . 777 .555 .406 % 17.64 19.97 15.32 14.70 17.41 18.94 44.16 38.15 Round 1 CI (15.2, 20.1) (15.8, 24.2) (11.1, 19.5) (8.9, 20.5) (13.3, 21.5) (16.1, 21.8) (38.2, 50.1) (29.9, 46.4) 1999 n 2342 957 1349 408 885 555 2402 2566 % 14.81 21.01 10.63 9.08 13.77 17.92 36.16 31.76 Round 2 CI (12.8, 16.9) (16.4, 25.7) (8.1, 13.1) (6.6, 11.6) (11.1, 16.5) (15.1, 20.7) (32.1, 40.2) (27.5, 36.1) 2002 n 4095 1616 2165 620 1573 1902 4194 4321 SOUTH % 13.63 17.95 10.57 8.15 13.62 14.22 30.73 28.55 AFRICA Round 3 CI (11.6, 15.7) (15.3, 20.7) (7.8, 13.3) (4.0, 12.3) (9.9, 17.4) (12. 2, 16.9) (27.2, 34.3) (25.8, 31.3) Strong TAPS 2007 n 3692 1510 2168 210 1566 1916 3744 3965 Policy % 12.70 14.99 10.83 7.99 11.41 14.93 31.27 29.85 Round 4 CI (10.9, 14.5) (12.4, 17.6) (8,8, 12.9) (5.1, 10.9) (8.9, 13.9) (12.6, 17.3) (28.0, 34.5) (26.8, 32.9) 2011 n 3713 1512 2184 467 1322 1924 3755 3934 R1 v R 4* ∆ -0.280 -0.249 -0.293 -0.457 -0.345 -0.212 -0.292 -0.218 P .013 .067 .099 .038 .117 .026 .0001 .042

*Difference for South Africa calculated by comparing rounds 1 and 4

Table 5a: Significant Differences in Tobacco Advertising Exposure across GYTS Rounds, by Country Advertising Exposure Lot Some None % 53.29 33.10 10.92 Round 1 CI (50.5, 56.1) (30.3, 35.9) (8.5, 13.3) 1999 n 2579 SOUTH % 40.62 38.03 17.00 Round 2 AFRICA CI (38.1, 43.1) (34.9, 41.1) (14.4, 19.6) 2002 Strong TAPS n 4325 Policy % 35.13 40.17 19.75 Round 3 CI (32.6, 37.6) (38.2, 42.2) (17.4, 22.1) 2007 n 3974 % 32.24 40.22 23.83 Round 4 CI (30.2, 34.3) (37.9, 42.6 (21.1, 26.6) 2011 n 3947 R1 v R4 ∆ -0.395 0.215 1.182 P <.0001

Table 5b: Significant Differences in Tobacco Promotion Exposure across GYTS Rounds, by Country Promotion Exposure % 30.89 Round 1 CI (27.8, 34.0) 2000 NIGERIA n 914 No TAPS % 23.82 Round 2 Policy CI (16.3, 31.3) 2008 n 349 ∆ -0.229 P .041 % 20.57 Round 1 CI (17.8, 23.4) 2001 n 1073 BOTSWANA % 17.53 Round 2 Weak TAPS CI (15.1, 19.9) 2008 Policy n 1605 ∆ -0.148 P 0.058 % 21.89 Round 1 CI (20.5, 23.3) 2003 n 3782 TANZANIA % 16.32 Round 2 Weak TAPS CI (13.8, 18.9) 2008 Policy n 3597 ∆ -0.254 P <.0001

Table 5c: Significant Differences in Tobacco Sponsorship Exposure across GYTS Rounds, by Country

Sponsorship Exposure Lot Some None

% 33.12 35.72 28.73 Round 1 CI (29.5, 36.8) (32.1, 39.4) (25.2, 32.3) 2001 n 1073 BOTSWANA % 32.44 39.39 27.42 Round 2 Weak TAPS CI (29.8, 35.1) (36.1, 42.7) (24.9, 30.0) 2008 Policy n 1605 ∆ -0.021 0.103 -0.046 P 0.012 % 42.18 21.10 33.89 Round 1 CI (39.7, 44.6) (19.5, 22.7) (31.2, 36.6) 2003 n 3782

TANZANIA % 44.12 23.12 31.99 Round 2 Weak TAPS CI (41.0, 47.2) (20.7, 25.5) (28.0, 36.0) 2008 Policy n 3597

∆ 0.046 0.096 -0.056

P <.0001 % 29.74 58.00 11.05 Round 1 CI (25,0, 34.5) (53.8, 62.3) (8..9, 13.7) 2002 n 942 SEYCHELLES % 27.07 49.72 22.38 Strong TAPS Round 2 CI (22.3, 31.9) (45.1, 54.3) (19.2, 25.6) Policy 2007 n 844 ∆ -0.090 -0.143 1.026

P <.0001 % 46.23 35.51 16.44 Round 1 CI (43.1, 49.4) (32.9, 38.1) (13.0, 19.9) 1999 n 2579 % 38.83 40.48 18.95 Round 2 CI (35.2, 42.3) (36.9, 44.1) (16.3, 21.4) 2002 SOUTH n 4325 % 34.63 38.65 24.89 AFRICA Round 3 CI (31.7, 37.6) (35.6, 41.7) (22.4, 27.3) Strong TAPS 2007 Policy n 3974 % 29.33 41.25 26.90 Round 4 CI (27.0, 31.7) (38.5, 44.0) (24.9, 28.9) 2011 n 3947 R1 v R4 ∆ -0.366 0.162 0.636 P <.0001 *Difference for South Africa calculated by comparing rounds 1 and 4

3.5.9 Anti-TAPS Policy/TAPS Exposure and Change in Smoking Behavior

Change in Smoking Prevalence: The results of smoking prevalence differences by TAPS policy are presented in Table 6. Smoking prevalence decreased over time in countries with strong anti-

TAPS policies (OR 0.88, p =.001). This estimate remained significant when adjusted for demographic variables; however, after controlling for variables in the intermediary pathway for smoking, i.e. parents or peers who smoked, the decrease was no longer significant. Smoking prevalence in countries with weak anti-TAPS policies increased over time in the full model

(AOR 1.64, p=.008). No significant change in smoking prevalence over time was observed in countries without any TAPS policies.

Change in Susceptibility: The results of susceptibility to smoking by TAPS policy are presented in Table 7. No significant change in the prevalence of susceptibility to smoking was observed countries with strong anti-TAPS policies or in countries with no TAPS policies. However there was a significant increase over time in susceptibility to smoking among students in countries with weak anti-TAPS policies (AOR 1.51, p=.001).

3.5.10 Change in TAPS Exposure

Strong TAPS Policies: Countries with strong anti-TAPS policies showed a significant decrease over time in students’ exposure to tobacco advertising and sponsorship (AORs 0.77, p=<.0001 and 0.81, p= <.0001 respectively). No significant change in tobacco promotion exposure was observed over time in these countries.

Weak TAPS Policies: No change was observed in students’ exposure to tobacco advertising and sponsorship in countries with weak anti-TAPS policies; however, there was a significant decrease in tobacco promotion exposure over time (AOR .75, p=001).

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No TAPS Policies: No change in students’ exposure to tobacco advertising and promotion was observed over time in countries with no TAPS policies; however, there was a significant decrease in tobacco sponsorship exposure (AOR .63, p=035).

3.6 Discussion

A significant majority of UN member states and nations have ratified the FCTC agreeing to abide by its evidence-based provisions that are proven to reduce tobacco use and thus prevent the associated epidemic of disease and premature death. In response to the tobacco industry’s effective targeting of new markets and population groups with aggressive advertising, promotion and sponsorship, it is vital that countries implement FCTC Article 13 which calls for comprehensive TAPS bans. However, whether FCTC adoption in developing countries can provide the same protections and results achieved in developed, high-income countries remains to be demonstrated

This analysis sought to examine the impact of various policies that ban TAPS in African countries. Although all six countries ratified the FCTC between 2003 and 2007, four of them have enacted legislation that on some level bans TAPS; the laws of only two countries are considered to be strong regulations that are adequately enforced. Among the countries with existing TAPS bans, smoking prevalence was higher in middle income countries. Tanzania, a low-income, tobacco-producing country had a comparatively lower smoking prevalence of 2.7%.

This could suggest that student smoking prevalence may be associated with country income level. The cost of smoking, as measured by relative income price representing the percent of annual income required to purchase cigarettes, ranged from 3.5% to 9.7% for middle-income countries, whereas the cost for low-income countries was between 14.8% and 34.1% of annual

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Table 6: Logistic Regression Models of Change in Current Smoking Prevalence Across GYTS Rounds by Countries’ TAPS Policy Model A Model B Model C Model D Variables OR CI p OR CI p OR CI p OR CI p Year: Round 1 Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Round 2 0.88 0.82–0.95 .0014 0.88 0.81–0.95 .0014 0.99 0.91–1.07 .8277 1.03 0.95–1.13 .4805 Sex: Female Ref Ref Ref Ref Ref Ref Ref Ref Ref Male 1.68 1.40–2.01 < .0001 1.44 1.18–1.75 .0003 1.38 1.12–1.70 .0025 Age: 13 years Ref Ref Ref Ref Ref Ref Ref Ref Ref Strong 14 years 1.50 1.18–1.90 .1698 1.38 1.10–1.74 .1277 1.50 1.18–1.91 .0416 TAPS 15 years 1.79 1.42–2.26 < .0001 1.50 1.19–1.89 .0027 1.59 1.25–2.02 .0019 Policy Parents smoke 2.05 1.77–2.36 < .0001 1.96 1.68–2.28 < .0001 Close friends smoke 7.04 5.89–8.42 < .0001 6.54 5.43–7.88 < .0001 Advertising exposure 1.59 1.18–2.13 .0022 Promotion exposure 1.54 1.32–1.80 < .0001 Sponsorship exposure 1.46 1.17–1.82 .0007 Year: Round 1 Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Round 2 1.31 0.91–1.87 .1426 1.31 0.92–1.88 .1381 1.65 1.16–2.34 .0057 1.64 1.14–2.35 .0077 Sex: Female Ref Ref Ref Ref Ref Ref Ref Ref Ref Male 1.67 1.26–2.23 .0004 1.38 1.03–1.85 .0332 1.43 1.06–1.93 .0178 Age: 13 years Ref Ref Ref Ref Ref Ref Ref Ref Ref Weak 14 years 1.66 0.87–1.56 .8132 1.07 0.79–1.46 .9102 1.09 0.78–1.51 .9552 TAPS 15 years 1.42 1.02–2.00 .0251 1.18 0.84–1.66 .3036 1.17 0.79–1.74 .4185 Policy Parents smoke 2.85 2.28–3.56 < .0001 2.78 2.20–3.51 < .0001 Close friends smoke 6.41 5.06–8.12 < .0001 4.89 3.77–6.34 < .0001 Advertising exposure 1.30 0.91–1.88 .1562 Promotion exposure 2.94 2.26–3.83 < .0001 Sponsorship exposure 1.15 0.81–1.65 .4311 Year: Round 1 Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Round 2 0.77 0.48–1.25 .2895 0.91 0.58–1.43 .6779 1.11 0.70–1.76 .6617 1.12 0.69–1.80 .6522 Sex: Female Ref Ref Ref Ref Ref Ref Ref Ref Ref Male 1.13 0.59–2.19 .7071 1.03 0.55–1.94 .9235 0.97 0.50–1.89 .9313 Age: 13 years Ref Ref Ref Ref Ref Ref Ref Ref Ref No 14 years 0.86 0.42–1.76 .8144 0.77 0.34–1.76 .7486 0.90 0.40–2.03 .9556 TAPS 15 years 0.86 0.39–1.91 .8497 0.74 0.29–1.91 .6533 0.78 0.28–2.14 .6461 Policy Parents smoke 3.03 1.12–8.18 .0292 2.42 0.94–6.27 .0682 Close friends smoke 8.16 3.08–21.59 < .0001 8.24 3.06–22.16 < .0001 Advertising exposure 1.41 0.55–3.61 .4705 Promotion exposure 1.37 0.80–2.36 0255 Sponsorship exposure 1.12 0.55–2.30 .7561

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Table 7: Logistic Regression Models of Change in Smoking Susceptibility Across GYTS Rounds by Countries’ TAPS Policy Model A Model B Model C Model D Variables OR CI p OR CI p OR CI p OR CI p Year: Round 1 Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Round 2 0.91 0.82–1.00 .0539 0.90 0.82–1.00 .0390 0.99 0.91–1.08 .7852 1.02 0.94–1.12 .6077 Sex: Female Ref Ref Ref Ref Ref Ref Ref Ref Ref Male 1.33 1.16–1.53 < .0001 1.14 1.00–1.30 .0444 1.10 0.96–1.26 .1698 Age: 13 years Ref Ref Ref Ref Ref Ref Ref Ref Ref Strong 14 years 1.07 0.89–1.27 .4275 0.96 0.80–1.14 .3129 0.95 0.77–1.15 .3596 TAPS 15 years 1.25 1.05–1.50 . 0021 1.04 0.88–1.24 .2896 1.02 0.85–1.22 .4951 Policy Parents smoke 1.51 1.35–1.68 < .0001 1.49 1.33–1.68 < .0001 Close friends smoke 4.93 4.38–5.55 < .0001 4.59 4.01–5.16 < .0001 Advertising exposure 1.39 1.16–1.67 .0004 Promotion exposure 1.83 1.60–2.09 < .0001 Sponsorship exposure 1.13 0.95–1.35 .1601 Year: Round 1 Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Round 2 1.24 0.95–1.62 .1080 1.29 0.99–1.68 .0582 1.58 1.21–2.05 .0008 1.51 1.23–2.12 .0006 Sex: Female Ref Ref Ref Ref Ref Ref Ref Ref Ref Male 1.26 1.04–1.52 .0166 1.08 0.89–1.31 .4294 1.05 0.86–1.29 .6416 Age: 13 years Ref Ref Ref Ref Ref Ref Ref Ref Ref Weak 14 years 1.25 1.01–1.53 7500 1.19 0.96–1.48 .9513 1.17 0.92–1.48 .6572 TAPS 15 years 1.63 1.31–2.04 < .0001 1.44 1.13–1.83 .0035 1.47 1.11–1.94 .0043 Policy Parents smoke 2.48 2.06–2.98 < .0001 2.38 1.96–2.90 < .0001 Close friends smoke 4.39 3.72–5.19 < .0001 3.83 3.17–4.63 < .0001 Advertising exposure 0.93 0.72–1.20 .5728 Promotion exposure 1.98 1.46–2.69 < .0001 Sponsorship exposure 1.34 0.99–1.80 .0592 Year: Round 1 Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Round 2 0.72 0.50–1.04 .0819 0.79 0.55–1.14 .2095 0.91 0.60–1.38 .6481 0.95 0.60–1.51 .8178 Sex: Female Ref Ref Ref Ref Ref Ref Ref Ref Ref Male 1.52 1.14–2.03 .0044 1.55 1.13–2.13 .0070 1.62 1.11–2.36 .0119 Age: 13 years Ref Ref Ref Ref Ref Ref Ref Ref Ref No 14 years 1.08 0.60–1.97 .8849 0.93 0.48–1.80 .8540 1.19 0.62–2.30 .7043 TAPS 15 years 1.10 0.64–1.87 .8085 0.96 0.57–1.62 .9583 1.16 0.63–2.11 .8184 Policy Parents smoke 2.40 1.39–4.13 .0017 2.14 1.26–3.63 .0050 Close friends smoke 5.57 3.18–9.75 < .0001 5.38 3.22–9.01 < .0001 Advertising exposure 1.29 0.93–1.81 .1306 Promotion exposure 3.12 2.29–4.24 < .0001 Sponsorship exposure 1.02 0.57–1.84 .9445

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Table 8: Logistic Regression Modeling of Change in TAPS Exposure across GYTS Rounds by Countries’ TAPS Policy Advertising Promotion Sponsorship Strong TAPS AOR 0.77 0.97 0.81 Policy p <.0001 .4231 <.0001 Weak TAPS AOR 1.04 0.75 1.13 Policy p .6536 .0007 .1948 No TAPS AOR 0.76 0.78 0.63 Policy p .0841 .1418 .0353

Estimates adjusted for age, sex, and smoking parent/peer

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income. So unaffordability of cigarettes in low-income countries would likely contribute to reduced use.

Despite the existence of tobacco control laws that restrict TAPS, some of which have been in place for a decade or more, student exposure to TAPS in all six countries remained high between the periods of data collection. Exposure to tobacco advertising in the media was particularly high, between 60% and 80%, along with tobacco sponsorship exposure which was between 58% and 79%.

However, a decline in students’ TAPS exposure and smoking behavior over time were observed in the countries where TAPS bans had been in place and enforced for years – South

Africa and Seychelles. In Botswana, where a TAPS ban had been enacted but unenforced, students demonstrated a significant increase in smoking behavior and positive attitude toward smoking and smokers over time. Countries with no policies that ban TAPS showed no change in exposure to tobacco advertising or sponsorship and no change in smoking behavior over time.

It has been noted that the tobacco industry tends to respond to public criticism of its marketing strategies by ‘self-regulating’ their TAPS activities across the region (Drope, 2011).

However, this may only indicate a change in tactic from direct advertising and promotion to less overt marketing methods that are nonetheless quite effective (Centre for Tobacco Control, 2013).

This may account for why levels of TAPS exposure continue to be high even for countries with strong policies; which reduce their effectiveness.

South Africa is an example of best practices in the implementation of strong anti-TAPS policies. The government has made a number of subsequent amendments to existing tobacco control laws in response to the industry’s changing strategies. Although TAPS exposure persists in South Africa, significant gains were realized between 1999 and 2011 – including a 28%

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decrease in current smoking; 30% decrease in cigarette experimentation; 22% decrease in susceptibility to smoking; 31% decrease in having a parent who smokes and 32% decrease in having a close friend who smokes. South African students’ attitudes to smoking and smokers were less positive over time, however, not substantially so; which may be due to continued high rates of TAPS exposure which contribute to increased acceptability of smoking as the norm.

Despite the encouraging declines in tobacco behavior, TAPS exposure remains high in

South Africa. The government has recently passed even stricter anti-TAPS laws prohibiting virtual advertising via electronic media or staged peer-to-peer communications; continued future assessment will be required to evaluate the impact of these latest restrictions.

Botswana is an example of the adverse consequences of weak enforcement of anti-TAPS policies. This is middle income country with increasing disposable income where TAPS exposure remains high and is increasing. Despite the existence of tobacco control programs and enacted anti-TAPS laws, student exposure to tobacco sponsorships increased significantly.

While parental and peer smoking exposure levels remained the same across GYTS rounds, current smoking among students increased 75%; experimentation with cigarettes increased 27% and susceptibility by a substantial 117%. The majority of students had a positive or neutral attitude toward smoking and smokers and the proportions increased across rounds. These results appear to demonstrate that without adequate enforcement of laws that ban TAPS, under the right circumstances as demonstrated by the situation in Botswana, the tobacco industry is successful in using TAPS to influence students’ tobacco behavior and attitudes.

Students’ neutral or positive attitude toward smoking and smokers is an area that will require additional research. As TAPS exposure levels remain high, social norms may change and tobacco will become increasingly appealing or acceptable adolescents as they mature. This

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would present the ideal market for tobacco as African economies improve and disposable income becomes more available.

This examination of six African countries provides evidence that anti-TAPS laws that are adequately enforced over time can be a viable part of an effective tobacco control program to reduce smoking behavior in the region. Such laws, if effectively implemented can help to stem the increase in TAPS exposure even as the industry becomes less overt with their marketing strategies. However, as alternative and new marketing strategies are used to target population groups, it remains to be seen how smoking behaviors and attitudes will be impacted and how

African governments will respond.

3.6.1 Limitations

There are a number of limitations that should be considered as it relates to this study.

First, the GYTS is a cross-sectional survey, therefore TAPS exposure and other variables studied may not be considered as causal of smoking or susceptibility. However, the GYTS data provides confirmation of previous studies and valuable information on the factors associated with smoking behavior, susceptibility and attitudes toward smoking. Second, the GYTS data is collected from adolescents between age 13 and 15 enrolled in school. Therefore, the results may not be generalized to 13 to 15 years across the general population - particularly as school attendance is comparatively lower across Africa. According to the World Bank website on secondary school enrollment – the most recent data on enrollment for each country was as follows: Uganda 28%; Tanzania 32%; Nigeria 44%; Botswana 82%; South Africa 94%, and

Seychelles 111% (World Bank, 2013). Third, the method of GYTS data collection is self-report and smoking is considered to be taboo for African adolescents. Students may under-report this behavior which could lead to social desirability bias. However previous school-based self-report

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surveys have been found to be highly valid under conditions of anonymity (Sussman, 1995).

Fourth, it is possible that student’s tobacco-related attitudes were already established prior to enactment of the laws, therefore implementation of the policies may not have significantly influenced their behaviors or attitudes. Fifth, the period of time between implementation of anti-

TAPS policies and collection of the final data round varied for each country. This time period was shortest in Tanzania – five years; there was a nine year time span in Botswana and

Seychelles; and South Africa collected their data at three, eight, and 11 years following adoption of anti-TAPS policies. However, the aim was to measure any change in TAPS exposure and smoking behavior over time and South Africa’s data show that significant differences can be observed as early as three years after policy adoption. Finally, variables such as religious beliefs and socioeconomic status which may be associated with smoking behavior and attitudes were not available for inclusion in this analysis.

3.6.2 Recommendation

Applying the lessons learned from the experiences in the six African countries, tobacco control should be a priority across the region. An important component of comprehensive tobacco control programs involves the adoption and effective implementation of policies that prohibit the advertising, promotion and sponsorship of tobacco. The application of this effective tool as outlined in the FCTC does not involve large amounts of resources, but it does require the political will of the government and support of civil society.

Countries need to adopt strong anti-TAPS policies and follow up by diligently monitoring and enforcing the laws. Countries with anti-TAPS legislation should examine their effectiveness and update or amend the policies to respond to the industry’s changing tactics. Further, countries need to enforce their laws using stiff penalties that will prevent the industry from circumventing

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the regulations and send a message that the government is serious about reducing TAPS exposure. Finally, based on best practices in countries that have successfully implemented

TAPS bans, it is essential that authority be given to a governmental entity to monitor compliance and levy penalties for violations of the laws. This agency must work in coordination with other ministries, such as health, finance, taxation, education; to ensure that there are no conflicts in applying the policy. It is also vital that the government collaborates with public health advocacy groups and civil society organizations to maximize the effectiveness of the policies by increasing public support and compliance with anti-TAPS policies.

As the continent gets a handle on the crippling epidemic of communicable diseases, every effort should be made to avoid the impending epidemic of tobacco-related disease and premature deaths. With global support and political will African countries can implement effective anti-

TAPS regulations and be in compliance with the FCTC Treaty that they have already endorsed.

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CHAPTER 4

AN ASSESSMENT OF POLICIES THAT BAN TOBACCO ADVERTISING, PROMOTION

AND SPONSORSHIP, POLICIES THAT PROMOTE ANTI-TOBACCO MESSAGES AND

CHANGE IN MALE SMOKING BEHAVIOR AND ATTITUDE: BEST PRACTICES IN

THAILAND AND TURKEY2

2 English, L.M., Hsia, J., Asma, S., Lee, J., Chumbler, N. and Muilenburg, J. To be submitted to Tobacco Control 116

4.0 Abstract

Background: The FCTC addresses the global tobacco epidemic through comprehensive evidence-based provisions that countries can implement to reduce tobacco use in their populations. Articles 12 and 13 of the Treaty is focused on warning the public about the dangers of tobacco use and banning the marketing of tobacco use via advertising, promotion, or sponsorships. Turkey and Thailand have both developed strong tobacco control programs in response to high prevalence of smoking, especially among males. Both countries have adopted policies in compliance with FCTC Articles 12 and 13.

Objective: This research paper will review the impact of tobacco control policies that address

FCTC Articles 12 and 13. The relationship between tobacco advertising, promotion and sponsorship and anti-tobacco messages on male smoking behavior and attitudes in Turkey and

Thailand over time will be examined.

Method: A secondary analysis of cross-sectional data from two rounds of the Global Adult

Tobacco Survey conducted between 2008 and 2012 in Turkey and Thailand. Several indicators of exposure to TAPS and anti-tobacco messages were examined as correlates of smoking outcomes. Estimates were compared between survey rounds for each country using round one as the referent year.

Results: The primary results found in Thailand showed no significant change in smoking prevalence over time between the two GATS round; also smokers who reported attempts to quit decreased by 27 percent and those with intent to quit decreased by almost 40 percent over time.

Male exposure to TAPS increased by 42 percent while there was a decrease in males who reported noticing anti-tobacco messages.

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The significant results in Turkey showed a 13.4 percent decreased in male smoking prevalence observed over time between the two GATS rounds. Smoking consumption remained unchanged, however, the proportion of males who reported never smoking increased by 33 percent over time. There was a slight increase over time in smokers who tried to quit and a significant increase in those who reported intent to quit. A decline in the percentage of males who smoked manufactured cigarettes was observed while the rate of hand-rolled smokers remained the same. Male exposure to tobacco advertising increased from 8.2 to 11.9 percent over time, as well as a significant increase in exposure to anti-tobacco messages.

Conclusion: This examination of tobacco control policies related to FCTC Articles 12 and 13 and their impact on male smoking behavior over time in middle income countries with high smoking rates demonstrates that effective enforcement of strong policies over time results in improved tobacco control outcomes. This can account for the outcome observed in Turkey. In case of Thailand, however, gaps in tobacco control policies decreased their effectiveness.

Keywords: Tobacco use; Smoking; Tobacco Advertising, Promotion, Sponsorship; Anti- tobacco advertising; Counter-tobacco; Turkey Tobacco Control; Thailand Tobacco Control;

Turkey Tobacco Industry; Thailand Tobacco Industry.

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4.1 Introduction

Tobacco use is the leading cause of preventable death globally. The World Health

Organization (WHO) reported that at least 1.3 billion people smoke – approximately one third of the world’s adult population, and another 200 million use other forms of tobacco (WHO Report,

2013). By 2030 it is projected that tobacco use will kill over eight million people per year; with

80 percent of these deaths occurring in low and middle-income countries (LMICs) (WHO

Report, 2013). Currently, the regions with the highest tobacco-related death rates are Europe and the Americas; this is due to a longer history of tobacco use among these populations. However, based on the time period between smoking initiation and development of related morbidities, the epidemic of tobacco-related disease and death is soon expected to emerge within LMICs (WHO

Report, 2013).

The WHO’s Framework Convention on Tobacco Control (FCTC) is a treaty that was ratified by the United Nations in 2005; it addresses the global tobacco epidemic through comprehensive evidence-based provisions designed to reduce the supply of and demand for tobacco and thereby prevent tobacco-related death and disease. Based on the FCTC provisions, the WHO developed an MPOWER package for adoption by 177 member countries that have ratified the Treaty. The package consists of tobacco prevention policies and interventions proven to reduce tobacco use and is also used to measure countries’ progress in meeting the requirements of the FCTC provisions (see Figure 1).

The ‘W’ in MPOWER means to “warn about the dangers of tobacco” – this is based on

Article 12 of the FCTC which addresses the use of mass media to provide health education, communication, training and public awareness about tobacco. Countries with the most effective comprehensive tobacco control programs use mass media to inform the public about the

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M Monitor tobacco use through systematic surveys designed to assess tobacco prevention policies and evaluate their impact P Protect people from tobacco smoke  completely smoke-free environment in all indoor public spaces and workplaces O Offer help to quit tobacco use  accessible services to manage tobacco dependence clinically W Warn about the dangers of tobacco  high levels of awareness of the health risks of tobacco use across the population E Enforce bans on tobacco advertising, promotion and sponsorship (TAPS)  complete absence of TAPS. R Raise taxes on tobacco products  progressively less affordable tobacco products

Figure 1: WHO MPOWER Tobacco Control Policy Measures Source: WHO Report, 2008

harm of tobacco use. Research shows that hard-hitting anti-tobacco mass media campaigns – via television, radio, newspapers, posters, leaflets, warning labels, etc. – increases awareness of the danger of tobacco use, encourages smokers to quit and maintain abstinence in non-smokers

(WHO Report, 2013).

The use of anti-tobacco mass media campaigns is increasing; about 54 percent of the world’s population lives in countries that have aired at least one national anti-tobacco mass media campaign during the past two years (WHO Report, 2013). However, half of countries in low, middle, or high income bracket have not used any type of national mass media campaigns in the past two years to inform the public about the harms of tobacco use or encourage them to quit

(WHO Report, 2013). The adoption of Article 12 will require further effort to encourage countries to implement its provisions.

Another effective health communication intervention is the use of pictorial warning labels on cigarette packets. Research shows that warning labels that graphically depict the health effects of tobacco use are effective in educating smokers and non-smokers about the health risks of tobacco use (Fong, 2009). It has further been demonstrated that warning labels increase

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smokers’ thoughts about the health risks and their intension to quit smoking (Fong, 2009). The use of pictorial warning labels, first implemented by Canada in 2001, reduced smoking prevalence in that country by an estimated 2.9 to 4.7 percentage points over a decade (Huang,

2013). Over 40 countries now use this effective method as a component of their comprehensive tobacco control program (Huang, 2013).

The tobacco industry spends billions of dollars annually on various direct and indirect advertising, promotion and sponsorship strategies that successfully markets tobacco products and tobacco use. Article 13 of the FCTC requires countries to avoid the effect of tobacco advertising, promotion and sponsorship (TAPS) by enacting comprehensive bans on all types of TAPS. This provision is linked to the MPOWER measure “E” – which means to “enforce bans on tobacco advertising, promotion and sponsorship”. Effective policies that totally prohibit TAPS are among the most powerful tools that countries can implement to protect their population from the danger of tobacco. A comprehensive ban on all TAPS could decrease tobacco consumption by an average of about 7 percent, with some countries experiencing a decline in consumption of up to

16 percent (WHO Report, 2013). According to the WHO 2013 Global Tobacco Control Progress

Report, only 24 countries reported implementation of a comprehensive ban on all TAPS – this represents just below 10 percent of the world’s population (WHO Report, 2013).

Two middle-income countries that have implemented strong tobacco control programs with comprehensive policies that regulate TAPS and sponsor anti-tobacco campaigns are

Thailand and Turkey. These countries were motivated to develop tobacco control programs due to high rates of smoking in their populations, particularly among males. Female smoking rates in both these countries are significantly lower than males; i.e. women smoke 69 percent less than men in Turkey and 83 percent less than males in Thailand (CDC, 2013a). The WHO published

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four tobacco control progress reports (2008, 2009, 2011, and 2013) in which countries are rated based on their progress in applying the FCTC-related MPOWER measures. According to the

WHO ratings over this time period, Thailand and Turkey have made remarkable progress in complying with the FCTC guidelines (see Appendix A: Tables A2 and A3). These countries are the only middle income nation to have completed two rounds of the national, standardized

Global Adult Tobacco Survey which would allow for an assessment of smoking behavior over time in their population. It is important to assess how these countries have applied and enforced tobacco control policies and examine the impact on smoking behaviors and attitudes.

This paper will examine tobacco control policies related to FCTC Articles 12 and 13, including TAPS bans and anti-tobacco messages, and their impact on male smoking attitudes and behavior in Thailand and Turkey over time (females were excluded from the analysis due to relatively lower smoking prevalence). The hypothesis is that effective enforcement of strong policies over time should result in improved tobacco control outcomes. Data from two rounds of the Global Adult Tobacco Survey (GATS) data for Thailand and Turkey will be used to assess these relationships.

Documenting the successes and challenges of tobacco control policies in these countries will provide important information that could assist tobacco control efforts in other middle- income countries. Turkey and Thailand cannot be directly compared due to differences in their tobacco control history and timelines as described below; however, of the 86 countries that are categorized as middle-income by the World Bank, both countries have made significant attempts to address the tobacco epidemic and are the only countries to have completed two rounds of the

GATS survey that can monitor the impact of their efforts. Thus they represent good examples for those attempting to curb the tobacco epidemic.

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4.2 Background

4.2.1 Tobacco control in Thailand

Thailand signed the WHO FCTC in 2004 and ratified the treaty in March 2005. The country has a longstanding history of tobacco control activities since the 1980s when male smoking rates reached a peak of over 60 percent (TRC, 2008). See Tables 1 and 2 for the country profile of tobacco-related indicators and interventions.

As a tobacco producing country Thailand produced 72,000 tons of tobacco in 2009 which was a slight reduction over the previous decade (Eriksen et. al, 2012). Cigarette production has been managed by the government since 1939 through the Thailand Tobacco Monopoly (TTM) within the Ministry of Finance. In 1991 foreign imports were allowed into the country and by

2007 imported cigarettes represented almost 25% of the market - up from 2.7% in 1992 (TRC,

2008). In response to a decrease in market share the TTM recently approved the launch of two relatively inexpensive brands of Thai cigarettes targeted to low-income smokers. Sales of these two new brands, named SMS American and SMS Menthol, increased in 2012 by 25% and 18% respectively over the previous year (TTM, 2012).

The TTM’s 2012 Annual Report stated that a strategic priority of their marketing policy was to “expand sales channels as well as develop a product of international standard that meets customers’ needs in order to maintain the existing market shares.” Among their goals listed in strategic plans for 2013-2017 was to “construct new factories for business growth” and “be responsible for society” (TTM, 2012).

The manufacture of loose tobacco at the local level, operated by individual farmers, represents a significant component of Thailand’s tobacco production. Loose tobacco is used for hand-rolled cigarettes; about half of Thai smokers use hand- rolled or ‘roll-your-own’ and the

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Table 1: Country Profile: Tobacco-related Indicators

Adult Smoking Youth Smoking 1 Tobacco-related 5 Cigarette 2 Average Excise Tax RIP Population Income 3 Prevalence (%) Prevalence (%) death rate (% of (affordability) consumption price/pack 4 Overall M F Overall M F (2004) M F price/pack

THAILAND 67 million Middle 26.9a 46.4 7.6 11.7b 17.4 4.9 560 16.0 10.7 $2.56 62% 3.67%

TURKEY 75.6 million Middle 27.1c 41.9 13.1 23.0d 22.1 16.6 1399 37.6 5.8 $4.38 63% 2.88%

1. Average per capita consumption, Tobacco Atlas (Eriksen et. al, 2012) 2. Tobacco-related death per 100,000, Tobacco Atlas 3. 2010 U.S. equivalent dollars 4. Tobacco Atlas 5. Relative Income Price (% of annual per capita income required to purchase 100 packs) Tobacco Atlas a. 2011 Global Adult Tobacco Survey (CDC, 2013a) b. 2009 Global Youth Tobacco Survey (CDC, 2013b) c. 2012 Global Adult Tobacco Survey (CDC, 2013a) d. 2005 Global Youth Tobacco Survey (CDC,2013b)

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Table 2: Country Profile: Tobacco Control Interventions ACTIVITY YEAR THAILAND YEAR TURKEY National Tobacco 1989 The National Committee for the Control of Tobacco Use formed 2006 Prime Minister launched the National Tobacco Control Control Program under the Ministry of Public Health Programme and Action Plan of Turkey for 2008 – 2012 established First Tobacco Control 1992 Tobacco Control Product Act & Non-smokers’ Health Protection Act 1996 Law 4207 Prevention and Control of Hazards of Tobacco Law B.E. 2535 - Enforcement weak Products - Ban on advertising, promotion, sponsorship – exceptions - considered weak and unenforced - Regulate public indoor smoking-designated non-smoking areas - Regulate product packaging and pictorial warning labels - Public education campaigns - Cessation assistance FCTC Ratified 2004 November 8, 2004 2004 December 31, 2004 Subsequent Tobacco 2002 - Amendments to expand and enforce the laws: 2008 Amended Law 4207 to become one of the leading tobacco Control Legislation 2010 - Expanded the warning label size (50% of pack) and graphical content control laws worldwide: - Comprehensive ban on public indoor smoking - Comprehensive ban on advertising, promotion, - Prohibit point-of-sale display – product advertising sponsorship – few loopholes - Prohibit public indoor smoking - Regulate product packaging and warning labels - Public education campaigns - Penalties for violations GATS – 1st Round 5/2009 Male smoking prevalence – 45.6% 11/2008 Male smoking prevalence – 47.9% Female prevalence – 3.1% Female prevalence – 15.2% Overall – 23.7 % Overall – 31.3% GATS – 2nd Round 12/2011 Male smoking prevalence – 46.6% 5/2012 Male smoking prevalence – 41.4% Female prevalence – 2.6% Female prevalence – 13.1% Overall – 24.0% Overall – 27.0% Additional Tobacco 1993 Excise tax levied for health reasons – funds used for health promotion 2012 Price of tobacco increased above inflation. Cigarettes taxed Control Measures National Tobacco Control Policy – to reduce smoking to 21% by 2006; at 78% of retail price (2/2012) 2002 prevent youth initiation; protect from SHS; reduce per capita consumption Amended Tobacco 2012 Increased taxes on manufactured cigarettes – taxed at 69% of retail price 2012 Additional amendments to Law 4207 passed: Control Legislation (2/2012). Roll-your-own cigarettes lower priced. - Banned indirect advertising of logos, names, designs, etc. on non-tobacco products 2013 Added information on cessation help on cigarettes packs - Banned tobacco sales to minors under 18 Attempted to increase size of graphic warning label to 85% - - Pictorial warning on water pipes unsuccessful due to Philip Morris law suit. - Municipal police authorized to impose penalties

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rest smoke manufactured cigarettes. The prevalence of roll-your-own (RYO) cigarettes is highest in rural areas among groups with lower socioeconomic status and education (Ministry of Public

Health Thailand, 2009).

In 1992, the Thai government enacted two major pieces of tobacco control legislation: 1) the Non-smoker’s Health Protection Act which made public places completely smoke-free; and

2) the Tobacco Products Control Acts which banned all types of tobacco advertising and promotion – however, industry sponsorship was not addressed. Following the 1992 law, the

Ministry of Health issued several notices of rules, procedures and conditions: i.e. banned cigarette displays at points-of-sale in 2005; regulated health warnings on loose tobacco in 2007; regulated health warnings for cigarettes in 2009; and issued statements that required the listing of cigarette toxins and carcinogens content on packets in 2011. Further, the government sought to improve compliance with these policies through monthly monitoring checks by law enforcers and tobacco control networks to address policy violations.

Most recently, a 2013 Ministry of Health notice required the printing of smoking cessation information on cigarette packs and increasing the size of graphic warning labels to cover 85 percent of the pack. However, in November 2013 Philip Morris won a suit to block enforcement of the larger warning labels. Also, Thailand’s award winning mass-media campaigns, developed by non-governmental agencies such as ThaiHealth, Action on Smoking, and Health Foundation Thailand, have been successful in raising public awareness about the dangers of smoking and second-hand smoke.

According to WHO Global Tobacco Epidemic Reports, the MPOWER ratings ranked

Thailand among the most FCTC-compliant countries since 2008 (see Appendix A2). Thailand

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received maximum scores for monitoring tobacco use through surveillance; protecting the public through smoke-free policies; warning the public with large, color graphic labels on cigarette packs; implementing policies that ban advertising; and levying adequate taxation on cigarettes.

Moderates scores were given for compliance with TAPS bans and smoke-free policies - these areas of enforcement appear to be more of a challenge for policy-makers.

In 2011, the economic industry forecasters noted cigarettes decreased in volume sales and growth in tobacco smoking slowed down. The increased price and extensive anti-smoking campaigns conducted by the government and health organizations were ‘blamed’ for the slowdown. The forecasters project that a “tough situation for tobacco consumption is expected over the forecast period. Smoking is becoming an increasingly antisocial activity, and no longer appeals to the younger generation in terms of fashion. As a result, it is becoming more difficult to cultivate new smokers. In addition, people are becoming more health-conscious due to mandatory health checks” (Euromonitor International, 2012).

Thailand has received accolades for implementing strong tobacco control policies.

However, after a significant decrease in male smoking prevalence during the past two decades, the decline has stalled (See Figure 2). The rate of smoking remains stubbornly high in males and the reasons for this stall should be examined further.

4.2.2 Tobacco Control in Turkey

Turkey signed the WHO FCTC in 2004 and ratified the treaty in March 2005. The government then began the implementation of a comprehensive tobacco control program in

2006. The average per capita consumption of cigarettes in Turkey is among the highest rates in

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TRC Data* GATS Data**

2001 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 1981

Figure 2: Male Smoking Prevalence Trend in Thailand, 1981 – 2011 Sources: * Tobacco Control Research and Knowledge Management Center (TRC, 2008) ** Global Adult Tobacco Survey (CDC, 2013a)

the world. See Tables 1 and 2 for the country profile of tobacco indicators and interventions.

Turkey is a tobacco producer. In 2009, 85,000 tons of tobacco was produced, however, this reflects a reduction of 57.6% since 2000 (Eriksen, 2012). Until the 1980s, the government owned and operated TEKEL – the tobacco monopoly – which dated back to Ottoman times. As multinational tobacco companies were permitted to import their products, unrestricted cigarette advertising became pervasive. Cigarette sales almost quadrupled between 1960 and 2000, going from 30 billion sticks in 1960 to about 120 billion in 2000. In the aftermath of privatization, the government established the Tobacco and Alcohol Market Regulatory Authority in 2002. The

Authority’s mission was to “regulate tobacco and alcoholic beverages, taking into account the economics of the country, as well as public health concerns, and also protection of social values 128

of the community” (Ministry of Health Turkey, 2010). A national tobacco control unit within the

Ministry of Health was created in 2006 and charged with implementing a national tobacco control program and plan (Bilir, Ozcebe, Erguder & Mauer-Stender, 2012).

In 2008, the government amended the weakly enforced 1996 Law on Prevention and

Control of Hazards of Tobacco Products. The amendments prohibited public smoking; tobacco advertising, promotion and sponsorship with penalties for violations; it regulated tobacco product packaging and labeling; and provided public education campaigns. Another provision of the new law increased tobacco products taxation – this effectively doubled the price of cigarettes over the past decade (Bilir et. al, 2012). Although the price per pack is still somewhat low ($4.50 USD equivalent) as compared to most of Europe.

The 1996 law banned advertising and promotion of tobacco products, but did not address sponsorship; the 2008 amendment strengthened this provision and included a ban on sponsorship; although charitable contributions by tobacco companies was allowed – public announcements or advertising about their contributions was prohibited. Cigarette brands could not be promoted using non-tobacco products. The law went further by banning the sale of less than a full pack or individual sticks of cigarettes. Electronic sales, such as Internet and telephone shopping were banned. Point-of-sale advertising was restricted so that the ads could not be placed outside shops. Due to the industry’s efforts to circumvent these policies by announcing frequent price changes in ways that could be construed as advertising, a 2011 regulation called for retailers to keep tobacco products in closed cases that were not visible to customers; the sales clerk would have to provide the product upon request.

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Previous tobacco control regulations directed the Turkish-owned media to devote at least

90 minutes of programming per month at specified times to inform the public about the hazards of tobacco use. An educational curriculum was developed to instruct students on the dangers of tobacco use. Recently, a public media campaign was created in Turkey with hard-hitting ads that portray the detrimental impact of tobacco use. In 2013, pictorial warning labels that had been mandated for cigarette packs were required for water pipes used to smoke tobacco.

According to WHO Global Tobacco Epidemic Reports the MPOWER ratings for Turkey went from being ranked among the least compliant in 2008 to being the most compliant in 2013.

(See Appendix Table A3). Turkey received the highest scores for all components of the

MPOWER measures.

The economic industry forecasters project that rising health awareness and increasing prices have resulted in reduced smoking in Turkey (See Figure 3). Although the industry’s value rose in 2011 as a result of unit price increases, volume sales recorded a decline (Euromonitor,

2012). The decline was primarily caused by reduced cigarette sales as they represent the largest category of tobacco products in Turkey (Euromonitor, 2012) (See Figure 4). As a result of aggressive action to reverse the tobacco epidemic, Turkey has been widely recognized in the global public health sector as a leader in tobacco control. However, the impact of these policies is just taking hold and the effects of these policies will require ongoing monitoring and evaluation.

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Number 1800 1600 1400 1200 1000 800 600 400 200 0 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010

Figure 3: Annual per Capita Cigarette Consumption Trend in Turkey, 1935 - 2011 Source: Tobacco Control in Turkey, WHO, European Regional Office (Bilir, 2012)

4.3 Methods

4.3.1 Global Adult Tobacco Survey

This study involved secondary analysis of publicly available data from the Global Adult

Tobacco Survey. The GATS is a nationally representative household survey that was designed in

2008 to measure key tobacco control indicators. A multistage cluster sample design is used to select households proportionally according to the country’s population. The questionnaire is administered in private to adults aged 15 years and older by trained field interviewers using electronic data collection devices. A standardized protocol determines household eligibility and identifies a list of household members; one person per household is randomly selected to complete the survey. It includes questions on background characteristics, tobacco smoking, smokeless tobacco use, cessation, second-hand smoking exposure, tobacco purchase patterns and

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Billion sticks 140

120

100

0 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010

Figure 4: Annual Cigarette Sales in Turkey, 1935 – 2011 Source: Tobacco Control in Turkey, WHO, European Regional Office, 2012

price, exposure to pro- and anti-tobacco media, and knowledge, attitudes and perceptions about tobacco.

The overall GATS response rate was above 90% in both countries. In Thailand, the number of households interviewed for each round was over 20,000; and in Turkey over 9,000 – see Table 3 for additional details (Ministry of Public Health Thailand, 2009, 2012; Ministry of

Health Turkey 2010, 2013).

Table 3: Global Adult Tobacco Survey Response Rates by Country and Round Response Rate (%) Interviews 2009 94.2 20,566 Thailand 2011 96.3 20,606 2008 93.7 9,030 Turkey 2012 90.1 9,851

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4.3.2 Measures

Smoking behavior, including current cigarette smoking versus never smokers, consumption (average number of cigarettes smoked per day), and quit attempts (made a quit attempt within past year) were considered as outcome variables. Also included were smokers’ intention to quit within a year and belief that smoking was dangerous. The analysis included male adults aged 15 years and older who were current smokers – smoked one or more days in the past month; former smoker – had not smoked within the past year; and never smokers.

Several indicators of exposure to TAPS and counter tobacco messages were examined as correlates of smoking outcomes; exposures was measured based on responses to the questions listed in Appendix B Table B2.

4.3.3 Data Analysis

All estimates and 95% confidence intervals were calculated on weighted data using

Statistical Analysis Software (SAS) Callable SUDAAN version 9.3, which estimates variances while accounting for the clustered sample design. Frequency counts were computed for the respondent’s demographic variables and were analyzed for the distribution of respondents by smoking behavior status for each variable listed in Table B2. Differences were compared between survey rounds for each country - using round one as the referent year to determine change in selected characteristics between the two data collection time periods. Comparisons were considered to be statistically significant when 95% confidence intervals did not overlap.

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4.4 Results

4.4.1 Thailand

The demographic data for males collected for both GATS rounds (May, 2009; December,

2011) in Thailand are presented in Table 4. There are no significant demographic differences between the samples from each round.

Comparison of male smokers’ behavior, knowledge and attitude over time: No significant change in male smoking prevalence was observed between the two GATS rounds. The rate of smoking among males was 45.6% in 2009 and 46.6% in 2011 (See Table 5). In 2011 smoking prevalence rose by 6% among those aged 25 to 44 years and declined by 10% among those over

65 years old. Smoking prevalence decreased among urban males going from 41.9% in 2009 to

39.6% in 2011.

The overwhelming majority of smokers continued to believe that smoking caused serious illness; there was no significant change in the proportions over time going from 97.3% in 2009 to

96.3% in 2011. Smoking consumption also remained unchanged – the average number of cigarettes smoked per day in 2009 compared to 2011 was 11.3 and 11.5 respectively.

There were no differences in the type of cigarettes that males preferred; 18.4% smoked manufactured cigarettes in both 2009 and 2011. The rates of hand-rolled cigarette users remained just about the same at 15.8% in 2009 and 16.4% in 2011. Those who used both types of cigarettes also did not change at 11.2% in 2009 and 11.7% in 2011.

Among current and former male smokers, the proportion of those who had quit within the last 12 months decreased significantly (26.9 percent) across GATS rounds; going from 49.9% in

2009 to 36.5% in 2011 (see Table 5). Current smokers who reported intentions to quit within the

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next 12 months decreased significantly by 39.7 percent; from 23.7% in 2009 to 12.3% in 2011.

Although high numbers of smokers noticed pictorial warnings on the cigarette packages about the dangers of smoking, there was a slight decrease in those who noticed them in 2011; from

93.5% in 2009 to 89.6% in 2011. Fewer smokers who reported noticing health warnings on the cigarette packages were led to thoughts of quitting smoking by the warnings; going from 67.8% in 2009 to 62.9% in 2011.

Change in TAPS Exposure: Males’ exposure to any tobacco advertising, promotion or sponsorship over the time period increased sharply by 42 percent. Tobacco advertising exposure, in particular, increased dramatically by 160 percent going from 8.2% in 2009 to 21.3% in 2011; while there was a decrease in exposure to tobacco promotion and sponsorship (See Table 6).

Change in Anti-tobacco Message Exposure: High numbers of male smokers continued to notice health warnings on cigarettes packages; 95.4% in 2011 (see Table 6). However, there was a significant decrease in males who reported noticing messages or ads that encouraged them to quit or not start smoking; from 87.0% in 2009 to 80.7% in 2011.

Table 4: GATS 2009, 2011 Male Demographic Data, Thailand 2009 2011 Demographics % CI % CI Age 15-24 21.0 (19.2, 22.9) 20.1 (18.5, 21.8) 25-44 42.0 (40.3, 43.7) 40.7 (39.0, 42.4) 45-64 28.5 (27.2, 29.8) 30.1 (28.8, 31.5) 65+ 8.6 (7.9, 9.3) 9.1 (8.4, 9.8) Education < HS 52.1 (50.1, 54.1) 49.7 (47.8, 51.7) > HS 47.9 (45.9, 49.9) 50.3 (48.3, 52.2) Geographical location -Urban 30.2 (29.1, 31.3) 33.7 (32.3, 35.2) -Rural 69.8 (68.7, 70.9) 66.3 (64.8, 67.7)

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Table 5: Current Male Smokers’ Behavior, Attitude and Knowledge in Thailand across GATS Rounds Relative THAILAND GATS 2009 GATS 2011 change P % CI n % CI n Smoking 45.6 (43.8,47.4) 10052 46.6 (44.7, 48.4) 8781 0.022 0.151 Average # cigarettes per day 11.3 (10.9, 11.7) 4461 11.6 (11.1, 12.0) 3885 0.002 0.152 Believe smoking causes serious illness 97.3 (96.1, 98.1) 4473 96.3 (94.9, 97.3) 3891 -0.010 0.092 Quit attempt within past 12 months 49.9 (47.1, 52.7) 4601 36.5 (33.7, 39.3) 3997 -0.269 0.000 Intent to quit within next 12 months 23.7 (21.6, 26.0) 4474 14.3 (12.4, 16.5) 3890 -0..395 0.000 Noticed pictorial warnings on packs 93.5 (91.7, 94.9) 2879 89.6 (87.3, 91.5) 2486 -0.041 0.003 Text warning led to thoughts of quitting 67.8 (65.1, 70.4) 4472 62.9 (60.1, 65.5) 3885 -0.073 0.006

Table 6: TAPS and Anti-Tobacco Message Exposure in Thai Males across GATS Rounds Relative THAILAND GATS 2009 GATS 2011 change P % CI n % CI n Overall TAPS 19.9 (18.4, 21.6) 9907 28.4 ( 26.0, 31.0) 4175 0.423 0.000 TAPS Advertising 8.2 (7.1, 9.6) 9900 21.3 (19.0, 23.9) 3891 1.598 0.000 Promotion 10.1 (9.0, 11.2) 10036 7.6 (6.5, 8.9) 8742 -0.248 0.001 Sponsorship 6.0 (5.3, 6.9) 10046 4.5 (3.9, 5.3) 8763 -0.250 0.001 Health warnings on pack* 94.2 (93.1, 95.2) 4473 95.4 (94.2, 96.4) 3893 0.013 0.057 Anti-tobacco ads 87.0 (85.5, 88.3) 10017 80.7 (78.8, 82.4) 8759 -0.078 0.000 *Denominator – Male Smokers 0.000 indicates that p <0.001 for one-sided z test of percentage change

In summary, the comparison of Thai data over the 31 months between GATS rounds show that male smoking prevalence remained unchanged between 2009 and 2011. Male tobacco behavior and attitudes did not improve over time. Fewer males thought about quitting or attempted to quit smoking even though they were exposed to anti-tobacco messages. Male exposure to TAPS increased in 2011. An examination of the tobacco control situation in

Thailand will provide insight into the lack of progress observed in recent years.

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4.4.2 Turkey

The demographic data for males collected for both GATS rounds (November, 2008; May,

2012) in Turkey are presented in Table 7. There are no significant demographic differences between the two samples.

Comparison of male smokers’ behavior, knowledge and attitude over time: A significant reduction in male smoking prevalence was observed between the two GATS rounds. The rate of smoking among males was 47.9% in 2008 and 41.5% in 2012; this represents a reduction of 13.4 percent (See Table 8). In 2012 smoking prevalence declined across all male demographic subgroups i.e. ages, geographic location, and level of education.

The overwhelming majority of smokers continued to believe that smoking caused serious illness; however, there was a small decrease in the proportions over time – 97.5% in 2008 and

95.7% in 2012. Smoking consumption remained unchanged and relatively high – the average number of cigarettes smoked per day in 2008 compared to 2012 was 17.8 and 18.5, respectively.

Turkish males predominantly smoke manufactured cigarettes. There was a decline over time in the rate of males who smoked manufactured cigarettes from 43.1% in 2008 to 36.7% in

2012. However, there was no change across rounds in those who used hand-rolled cigarette

(2.0% and 2.1%) or both types of cigarettes (2.7% and 2.4%).

Among current and former male smokers there was a slight, but non-significant increase, in those who had tried to quit within the last 12 months; going from 44.1% in 2008 to 45.1% in

2012. Current smokers who reported intentions to quit within the next 12 months increased significantly by 26.1 percent; going from 27.6% in 2008 to 34.8% in 2012 (see Table 8). An observation of importance indicates that males who reported to be never smokers increased

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significantly by 33 percent across GATS rounds. The rate of males who never smoked went from 30.0% in 2008 to 39.9% in 2012 (See Table 9).

The overwhelming majority of smokers noticed pictorial warnings on the cigarette packages about the dangers of smoking and there was no significant change over time in those who saw the warnings; going from 94.8% in 2008 to 93.8% in 2012). In 2012, a question was added that asked smokers about the effect of the pictorial warning and 91.1% of smokers responded that these warnings led to thoughts about quitting.

Change in TAPS Exposure: Exposure to tobacco advertising, promotion or sponsorship in males did not increase substantially over the time period. However, there was a significant increase in advertising exposure from 8.2% in 2008 to 11.9% in 2012, while there a significant decrease in exposure to tobacco sponsorships from 5.3% to 2.8% (See Table 10).

Change in Anti-tobacco Message Exposure: High numbers of male smokers continued to notice health warnings on cigarettes packages; 94.8% in 2008 and 93.8% in 2012 (See Table 10).

There was a significant increase in the number of males who noticed messages and ads that encouraged them to quit or not start smoking; 89.1% in 2008 and 93.7% in 2012.

Table 7: GATS 2008, 2012 Male Demographic Data, Turkey 2008 2012 Demographics % CI % CI Age 15-24 22.5 (20.7, 24.4) 22.4 (20.7, 24.2) 25-44 43.8 (41.8, 45.8) 43.0 (41.2, 44.9) 45-64 25.6 (23.9, 27.3) 26.2 (24.7, 27.8) 65+ 8.2 (7.3, 9.1) 8.4 (7.5, 9.4) Education < HS 58.0 (55.5, 60.5) 62.4 (60.0, 64.8) > HS 42.0 (39.5, 44.5) 37.6 (35.2, 40.0) Geographical location -Urban 69.7 (68.1, 71.4) 71.7 (70.2, 73.1) -Rural 30.3 (28.6, 31.9) 28.3 (26.9, 29.8) 138

Table 8: Current Male Smokers’ Behavior, Attitude and Knowledge in Turkey across GATS Rounds Relative TURKEY GATS 2008 GATS 2012 change P % CI n % CI n Smoking 47.9 (45.9, 50.0) 4269 41.5 (39.4, 43.5) 4470 -0.134 0.000 Average # cigarettes per day 17.8 (17.2, 18.4) 2036 18.5 (17.5,19.5) 1782 0.040 0.095 Believe smoking causes serious illness 97.5 (96.7, 95.7) 2036 95.7 (94.0, 96.9) 1782 -0.019 0.016 Quit attempt within past 12 months 44.1 (41.5,46.6) 2173 45.1 (42.3, 47.9) 1902 0.024 0.172 Intent to quit within next 12 months 27.6 (25.1 30.3) 2036 34.8 (31.8, 37.9) 1782 0.258 0.001 Noticed pictorial warnings on packs N/A 93.8 (91.1, 95.3) Pictorial warning led to thoughts of quitting N/A 91.1 (88.8,93.0)

Table 9: Male Never-Smokers in Turkey across GATS Rounds, by Demographic Subgroups Relative TURKEY GATS 2008 GATS 2012 Change P % CI n % CI n Never smoked cigarettes 30.0 (28.1, 31.9) 4269 39.9 (37.9, 41.9) 4470 0.329 0.000

Table 10: TAPS and Anti-Tobacco Message Exposure in Turkish Males across GATS Rounds Relative TURKEY GATS 2008 GATS 2012 change P % CI n % CI N Overall TAPS 17.2 (15.4,19.1) 4251 18.3 (16.0, 20.9) 4470 0.064 0.158 TAPS Advertising 8.2 (6.9, 9.7) 4249 11.9 (9.9, 14.2) 4470 0.451 0.010 Promotion 7.8 (6.6, 9.1) 4269 6.8 (5.6, 8.3) 4470 -0.128 0.109 Sponsorship 5.3 (4.3, 6.4) 4269 2.8 (2.1, 3.7) 4470 -0.472 0.000 Health warnings * 94.8 (93.1, 96.0) 2036 93.8 (91.9, 95.3) 1782 -0.010 0.142 Anti-tobacco ads 89.1 (87.5, 90.4) 4269 93.6 (92.4,94.7) 4470 0.051 0.000 *Denominator – Male Smokers 0.000 indicates that p <0.001 for one-sided z test of percentage change

In summary a comparison of the GATS data collected at an interval of 42 months in

Turkey show a dramatic decrease in male smoking prevalence between 2008 and 2012. More males over time reported an intention to quit smoking within 12 months. The proportion of males who never smoked increased significantly in 2012. Exposure to TAPS overall did not

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increase significantly while exposure to anti-tobacco messages did increase. An examination of the tobacco control interventions implemented during this time should provide an explanation of the progress observed during this period.

4.5 Discussion

Thailand: Tobacco control policies in Thailand were developed in accordance with the

Framework Convention on Tobacco Control and smoking rates declined until the early-2000s.

Despite successful implementation of tobacco control measures in Thailand, there are areas for concern based on the GATS tobacco use results for males. In a comparison of the 2009 and

2011 data, male smoking prevalence did not significantly change over time between survey rounds. The declining trends in smoking rates observed during the 1990s and early 2000’s has stalled and smoking rates remains high – almost half of Thai men smoke. Additional GATS indicators of male smoking behaviors showed negative trends over time. While almost all smokers believed that smoking was dangerous to their health, 27 percent fewer smokers attempted to quit and 40 percent fewer smokers had intentions of quitting in 2011 compared to

2009.

Exposure to tobacco advertising increased by 160 percent in 2011 due to an increase in males who reported noticing tobacco-related signs at the points-of-sale in shops; while fewer men noticed anti-tobacco ads in 2011 compared to 2009. Fewer male smokers who noticed health warnings on cigarette packs reported that they led to thoughts of quitting. These indicators present significant areas of concern for tobacco control advocates.

Which tobacco control policies should Thailand reevaluate to address these areas of concern? An assessment of the country’s tobacco control enforcement efforts and other tobacco-

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related policies reveals that there are a number of issues that require attention. The following areas are among the challenges faced by tobacco control advocates in Thailand: i) Competing missions of government ministries: The Ministry of Public Health in Thailand issues notices that are intended to reduce tobacco use while the Ministry of Finance, works through the TTM to promote tobacco use and increase governmental tobacco revenue. The goals of these two agencies conflict – this is an area that the government will need to address by deciding which is more important to the long term health of the nation. ii) Promotion of low-cost cigarettes: Although the government increased the price of cigarettes by raising taxes in compliance with FCTC recommendations, TTM immediately introduced two new inexpensive brands with American-sounding names to maintain their market share. Sales of these new brands increased significantly, undercutting the effects of tobacco control policies. iii) Enforcement of advertising policies: The Thai law bans point-of-sale displays of cigarettes; and requires that cigarettes be stored out of the sight of customers with a sign that states

“cigarettes sold here”. In addition a Thai consumer protection law requires signs be posted that provides product price and information. This could be construed as advertising and may be responsible for the increase in point of sale advertising observed (SEATCA, 2008) (See

Appendix D). iv) Reduced effect of warning labels: In 2011 there was a 7.3 percent reduction in the proportion of smokers who reported that warning labels on cigarette packs led to thoughts of quitting. This may be due to the fact that eight of the ten graphic warnings had been in continuous use for the previous five years and that effectiveness may have decreased over time. Research shows that

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the impact of warning labels can diminish over time and so it is recommended that warning labels be rotated or updated to maintain their effectiveness (Fong, 2009) (See Appendix E). v) Misinterpretation of TAPS policies: The wording of Thai anti-TAPS policies leaves room for misinterpretation. For example, advertising and promotion is banned by the law, however, sponsorship is not specifically mentioned. The government considers sponsorship to be prohibited; however, the TTM continues to sponsor sports, education and community initiatives although brand logos are not used. TAPS policies should be clarified and enforced comprehensively for advertising, promotion and sponsorship. vi) Loose tobacco regulation: Approximately half of male smokers in Thailand use loose tobacco to roll their own cigarettes; the majority of RYO smokers live in rural areas and are less educated. Tobacco control policies such as warning labels, mass media campaigns, increased taxation, have not been applied to loose tobacco in the same way as manufactured cigarettes.

The government should make a concerted effort to effectively warn and protect RYO tobacco users about the dangers of smoking. Philip Morris recently used this argument in their successful litigation to curb tobacco control measures; their spokesperson stated, “…health warnings don’t apply to cheap, roll-your-own tobacco, which makes up half of Thailand’s market” (Birtles,

2013)

Although Thailand has strong tobacco control laws, it is clear that legal loopholes and gaps in enforcement have hampered their efforts to reverse the tobacco epidemic as male smoking rates are not declining and remain high. The Thai government should address these gaps in tobacco control policies and continue to monitor and strictly enforce their current laws to ensure that tobacco use gets back on a declining track.

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Turkey: Although Turkey enacted tobacco control laws since 1992, the government only began enforcing the current strict tobacco prevention policies relatively recently. In 2008 the tobacco control laws were amended to conform to the guidelines of the FCTC. According to the GATS data, smoking-related indicators have responded positively to the improved tobacco control policy measures. Male smoking prevalence decreased by 13% over the 42 months between the two surveys. Notably, during that time, males who reported having never smoked increased by

33%; whereas was no significant change occurred in the proportion smokers who tried to quit over the same period. Therefore the primary reason for the decline in smoking prevalence was due to younger males who joined the 2012 GATS cohort but never initiated smoking. In 2012, there was a significant increase in the percentage of male smokers who reported their intention to quit within a year; even though quit attempts did not increase significantly. Thus, a significant proportion of smokers would like to stop smoking and tobacco control initiatives should offer cessation assistance to help smokers achieve their goal.

There was no change in overall TAPS exposure between 2008 and 2012; however, there was a 10% increase in male exposure to cigarette advertising going from 8% to 12%. Exposure to tobacco promotion remained below 10% and sponsorship decreased by 47%; going from 5.3% to 2.8% over time. While almost all smokers were aware of the health dangers of smoking, there was a slight two percent decrease in those who believed that smoking causes serious harm. This discrepancy should be monitored in the future to ensure that the population remains fully aware of the health impact of smoking. Further, there was no change in smoking consumption over time, which remained relatively high at an average of 18.5 cigarettes per smoker per day. Over

90% of smokers noticed the pictorial warnings on cigarette packs; in 2012, 91% of them reported

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that the labels led to thoughts of quitting – which speaks to the effectiveness of the warning labels.

When asked about the reason for Turkey’s “improbably turnaround” Dr Nazmi Bilir, professor of public health at Haceteppe University, Ankara, Turkey, said, “To me it is the political commitment of the government,” he said, It’s a very powerful government, and the prime minister and the health minister and the head of the health commission in the parliament – these are very committed persons.” Dr. Bilir, a tobacco control advocate who also worked on the

GATS, added that nothing would have been possible without a strong civil society movement; he said “we worked very closely with the government and the parliament and provided them the scientific data” (WHO, 2013).

Turkey achieved remarkable tobacco control successes during the period of the two

GATS rounds. The effective implementation and enforcement of strong anti-tobacco laws are responsible for a significant decreased in tobacco use and increased awareness and support for tobacco control initiatives. Although Turkey has advanced significantly in the attempt to reverse the epidemic, the rate of male smoking is still high as four of every ten males smoke. It will require ongoing diligence in policy making, enforcement and monitoring to ensure that the declining smoking trend continues.

4.6 Conclusion

This examination of tobacco control policies related to FCTC Articles 12 and 13 and their impact on male smoking behavior over time in middle income countries with high smoking rates demonstrate that effective enforcement of strong policies over time can result in improved

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tobacco control outcomes; this was demonstrated in Turkey’s results. In the case of Thailand, however, gaps in their efforts have decreased their effectiveness.

Thailand and Turkey differ in their tobacco control history and in their approach to controlling the tobacco epidemic and as such the two countries cannot be directly compared.

However, there are lessons to be learned from their experiences. Thailand’s long term approach has been gradual in taking steps to address and strengthen tobacco control since the 1980s; however, this response has left significant gaps that require urgent attention. Initially, Thailand achieved success as smoking prevalence gradually fell; however, rates have stalled and it is incumbent on the government to rally the political will to address policy loopholes that hinder the success of tobacco control efforts

Turkey’s recent approach to enforcing tobacco control policies has been rapid and thorough leaving few gaps. The initial outcome has been successful; smoking prevalence has decreased significantly in a short time. However, it is important to note that the enforcement of tobacco control policies requires ongoing, dynamic efforts to address the changing strategies of the tobacco industry to market its product and maintain profit. It is anticipated that Turkey and

Thailand will continue to be models for FCTC implementation and that with continued and strengthened efforts the tobacco epidemic will be eradicated.

The tobacco related experience of these two middle income countries clearly demonstrates that in the case of Turkey, the political will and broad support of the government was essential for the implementation of effective tobacco control initiatives. Both countries achieved strong public support for tobacco control efforts through the advocacy of non- governmental public health organizations that promote anti-tobacco campaigns and increase

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accountability of the government and compliance by the tobacco industry. Finally, both countries committed to the collection of scientific data through GATS and other surveys that allow for the evaluation of tobacco control initiatives.

This examination of the tobacco control situation in Turkey and Thailand provides a number of lessons and best practices that may be applied in other middle-income countries faced with high tobacco use prevalence. In summary, it is noted that the following components are key to the success of tobacco control efforts for these nations: 1) the political will and broad support of government; 2) strong civil society support through the alliance of non-governmental organizations; 3) solid scientific data to demonstrate the impact of tobacco use and the effectiveness of tobacco control measures.

4.6.1 Limitations

There are a number of limitations that should be considered as it relates to this study.

First, the GATS is a cross-sectional survey and as such no causal link can be made between smoking behavior and the tobacco control policies reviewed. However, the data trends observed support previous studies where such associations have been proven. Second, the differences between the two countries in the tobacco control history and policy approaches did not allow for a direct comparison in this analysis. However, the examples provided through the countries distinct experiences should be helpful to other nations in similar situations. Third, the length of time between GATS rounds for each country (31 – 42 months) may be considered as relatively short-term. However, the Thai data confirms the smoking prevalence trends which had been observed in previous studies and the Turkish data was able to demonstrate a change in smoking prevalence within four years.

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As Turkey and Thailand, along with other countries, continue their efforts to address the tobacco epidemic and repeat GATS in the future, additional studies will be necessary to measure their progress and develop additional policy recommendations that will improve the impact of their tobacco control programs and policies.

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CHAPTER 5

CONCLUSION

5.0 Overview

This final chapter will present the conclusion of the two studies and link the findings as they relate to the effectiveness of tobacco control policies in low and middle income countries.

It will connect the findings with the research questions presented in Chapters One through Four.

Finally, recommendations will be made that are vitally important for countries seeking to maintain a low prevalence of tobacco use and prevent the tobacco epidemic; and for countries with high smoking rates working to reverse the effects of the tobacco epidemic.

5.1 Background

Tobacco use continues to be the leading global cause of preventable death. The World

Health Organization (WHO) recognized the global threat of tobacco use and in 2003 negotiated the Framework Convention on Tobacco Control (FCTC) in an effort to prevent the death and disease associated with its use. This first ever health-related United Nations treaty has the potential to save millions of lives and dollars if it is adopted and implemented in a rapid and robust manner. The Treaty is founded on cost effective interventions that have been proven to reduce the impact of tobacco use. Six evidenced-based policy measures identified by the WHO, called MPOWER (see Figure 1.1), correspond to the FCTC guidelines. These guidelines are based on the experiences of several countries whose policies and interventions have been successful in reducing the impact of tobacco in their populations. However, most of these

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countries are developed nations and thus the studies used to prove the effectiveness of tobacco control interventions come from high-income countries. It is important to provide data and evidence to demonstrate that tobacco control measures can be effective in low and middle income or developing countries.

The objective of this research is to examine tobacco-related policies in low and middle income countries to assess their impact on smoking behaviors. The first study reviewed the impact of tobacco advertising, promotion and sponsorship (TAPS) exposure and anti-TAPS policies (laws that ban TAPS) on students’ smoking behavior over time in low and middle income African countries. The second study examined the impact of anti-TAPS policies and counter-tobacco advertising or messaging on male smoking behavior over time in two middle income countries with high tobacco use. The studies’ findings are used to provide recommendations that will improve the effectiveness of tobacco control policies related to TAPS and counter-tobacco messaging in low and middle income countries.

5.2 Research Questions and Findings

5.2.1. Study One

Questions: These research questions were designed to determine whether tobacco control policies that ban TAPS (anti-TAPS policies) can work in low and middle-income African countries to impact tobacco behavior in youth and may be summarized as follows:

i) Is there an association between smoking behavior or susceptibility and TAPS

exposure in LMIC African students?

ii) Are there differences in the level of students’ TAPS exposure over time as related

to the countries’ TAPS policies?

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iii) Are there differences in students’ smoking behavior over time as related to the

countries’ TAPS policies?

Findings: The research findings as they relate to the studies’ questions above may be summarized as follows: i) In reviewing the results for African students’ smoking behavior or susceptibility and the association with TAPS exposure, the findings suggest that there is an association. The Global

Youth Tobacco Survey data from the middle-income countries of South Africa and Botswana, demonstrate the relationship between TAPS exposure and smoking behavior and susceptibility.

Both countries implemented anti-TAP policies; however one government enforced a comprehensive strict policy whereas the other did not. South Africa’s strong anti-TAPS policy was associated with a significant decrease in students’ TAPS exposure and significant decreases in smoking behavior and susceptibility. Whereas in Botswana, the weakly enforced anti-TAPS policy correlated with no observed change in the level of students’ TAPS exposure and with significant increases in students’ smoking behavior and susceptibility. These findings support research previously conducted in high-income countries that demonstrate an association between

TAPS exposure and increased smoking and susceptibility to smoking. ii) A review of the results for the level of students’ TAPS exposure over time related to the strength of anti-TAPS policies show mixed, but positive results. The countries that implemented strong anti-TAPS policies showed a significant decrease over time in students’ exposure to tobacco advertising and sponsorship; however, no change in the level of tobacco promotion was observed over the same time period. The countries that implemented weak anti-TAPS policies demonstrated no significant change in students’ exposure to tobacco advertising and

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sponsorship; however, there was a significant decrease in tobacco promotion exposure during the same time period. While the countries with no existing anti-TAPS laws had no change in students’ exposure to advertising and promotion, a significant decrease in tobacco sponsorship was observed. iii) In assessing the results for the students’ smoking behavior over time as it relates to anti-

TAPS policies it may be concluded that there is a relationship between the policies’ strength and smoking behavior. Smoking prevalence among students decreased over time in African countries where strong anti-TAPS policies had been implemented whereas it increased over time in those countries with weak anti-TAPS policies. No change in students’ smoking prevalence was observed in countries without anti-TAPS policies.

Therefore, it may be concluded that strong anti-TAPS laws in low and middle income

African countries are associated with decreased student exposure to tobacco advertising and sponsorship and decreased smoking behavior and susceptibility, while weak anti-TAPS laws have no impact on the level of students’ exposure to advertising and sponsorship and is related to increased smoking behavior and susceptibility.

5.2.2 Study Two

Questions: These research questions were designed to determine the impact of tobacco control practices in middle-income countries with high male smoking prevalence.

i) Are there differences in male smoking prevalence and behavior over time as it

relates to the tobacco control policies in Thailand and Turkey?

ii) Are there differences in the levels of TAPS exposure and anti-tobacco messaging

over time as it relates to tobacco control policies?

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Findings: The research findings as they relate to the studies’ questions above may be summarized as follows:

i) In a review of the Global Adult Tobacco Survey (GATS) data for Thailand and Turkey there were differences in male smoking prevalence and attitude over time based on an assessment of differences in the tobacco control policies of each country. Turkey had strictly enforced their relatively new, but robust tobacco control policies banning TAPS and promoted effective public education campaigns that warned the public about the dangers of tobacco use; these initiatives are correlated with a dramatic decrease in male smoking prevalence over time. Further, between the periods of the two data rounds, there was an increase in the proportion of males who intended to quit smoking and in those who never started to smoke.

An assessment of Thailand’s tobacco control policies revealed that although their laws had been in place for decades, there were significant gaps in the enforcement of anti-TAPS laws and in the application of other related policies. This situation correlated with an observation of no change in male smoking prevalence over time. Further, during this time period there was a decrease in the proportion of males who attempted to quit smoking or reported that they intended to quit.

In conclusion, these findings demonstrate that effective enforcement of strong TAPS- related policies over time is associated with improved tobacco control outcomes even in middle- income countries where smoking rates are high and tobacco use has been ingrained in the culture for decades. Further, it is clear that ongoing progressive tobacco control efforts are required over time to maintain the impact of tobacco control policies or else earlier gains in reduced tobacco use may be reversed as was demonstrated in the case of Thailand.

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ii) According to the GATS data for both countries there were differences in the levels of exposure to TAPS and anti-tobacco messaging over time as related to differences in the countries’ tobacco control policies. Following Turkey’s strict enforcement of anti-TAPS laws and their aggressive promotion of anti-tobacco messages, the GATS data showed that TAPS exposure did not increase significantly over time while exposure to anti-tobacco messages did.

In Thailand, as loopholes in the anti-TAPS policies persisted, the data showed that TAPS exposure among males increased over time. Further, the mixed anti-tobacco messages disseminated by the government corresponded with a decrease in the proportion of males who reported that the tobacco health warning labels lead them to think about quitting.

In conclusion, these findings show that effective enforcement of anti-TAPS laws and effective anti-tobacco policies (i.e. counter-advertising and warnings) can result in decreased exposure to TAPS and increased exposure to anti-tobacco messages. Further, it is demonstrated that with adequate political will and civil society’s support, anti-TAPS policies can be effectively enforced and have a population-based impact in a relatively short period of time; the impact of

Turkey’s tobacco control policies were measureable within four years of enforcement.

5.3 Recommendations

Given that the findings of this research demonstration the effectiveness of comprehensive, strongly enforced anti-TAPS policies in reducing smoking behavior and susceptibility in youth from low and middle income African countries; and further that comprehensive anti-TAPS policies and anti-tobacco messages that effectively warn the public about the dangers of tobacco smoking work to reduce male smoking behavior over time in

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middle-income countries where smoking is endemic; adoption of the following tobacco control policies are highly recommended.

Recommendation One: Based on the results and findings of this research study, the immediate adoption, enforcement, and ongoing monitoring of strong, comprehensive anti-TAPS policies is highly recommended for all countries regardless of income level or smoking prevalence.

This recommendation is linked to the following study observations: i) Effective anti-TAPS policies can impact tobacco use in low and middle-income African countries. The countries of South Africa and Botswana provide contrasting examples of how students’ smoking rates and susceptibility are related to the way anti-TAP policies are adopted and implemented. South Africa’s strong tobacco control laws were associated with a decrease in students’ tobacco behavior whereas Botswana’s weaker laws were not.

The tobacco industry predicts that tobacco sales in low and middle income countries will increase as their economies improve and disposable income becomes available. (Euromonitor

International, 2013). The industry is aware that the unregulated marketing of tobacco will increase the prevalence of smoking in these populations and especially among youth. Therefore it is vital that countries not wait for the inevitable increase in smoking prevalence to occur prior to enacting comprehensive tobacco control laws that strictly ban TAPS; as it becomes more difficult for governments to regulate the tobacco industry’s actions after they have gained a foothold within the country. ii) Effective enforcement of comprehensive anti-TAPS policies is a viable part of tobacco control interventions in middle income countries with high rates of smoking. The example of Turkey demonstrates that even after years of inaction where tobacco use had become culturally

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ingrained, with the political will and support of civil society, effective enforcement of tobacco control policies can yield significant results within a relatively short period of time. iii) Anti-TAPS policies have to be comprehensive, up-to-date and strictly enforced to be effective. The weak or partial anti-TAPS laws enacted in countries such as Botswana, Tanzania, and Thailand, left loopholes that allowed for continual industry marketing that exposed the population to unacceptable levels of tobacco advertising, promotion or sponsorships. Moreover, even comprehensive laws that are strictly enforced must be updated or broaden on a regular basis to counter the persistent efforts of the industry to use new marketing methods or introduce new products. In Thailand for example, the tobacco laws control laws lost their effect when they were differentially applied to tobacco products and as new trends developed. South Africa on the other hand stayed on top of tobacco control efforts by repeatedly introducing policy amendments that regulated the industry’s latest marketing initiatives. iv) It is imperative for countries to be able to monitor and measure the impact of their policies on an ongoing basis. Tobacco control monitoring requires the collection of standardized national data that allows for the evaluation of tobacco-related indicators over time to analyze trends in behavior and policy impact. This study was restricted to those few countries with at least two rounds of data appropriate for analysis. Many countries have implemented tobacco control policies and are unable to evaluate the impact of their efforts due the lack of data. Conversely, many countries are on the verge of a tobacco epidemic and are unable to document it due to the lack of data.

It is important for international groups and philanthropies to provide assistance for low and middle income countries to develop and enforce strong comprehensive anti-TAPS laws.

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Technical assistance and resources should be made available to countries that are struggling to avoid the epidemic as well as those trying to avert one. Most low and middle income countries require assistance to collect national tobacco-related data and develop and enforce strong comprehensive tobacco control laws.

Recommendation Two: Based on the findings of this research study, it is highly recommended that all countries adopt and implement policies that promote anti-tobacco messages through government actions and mass media campaigns that effectively warn the public about the danger of tobacco use.

This recommendation is linked to the following study observations: i) Firm and unequivocal government tobacco policies and actions are vital in the effort to control tobacco use. In the case of South Africa and Turkey it was clear that the governments’ primary goal was to reduced tobacco use in their populations. The various governmental departments collaborated to regulate and enforce tobacco control policies and thus a clear anti-tobacco message was disseminated to the public and was understood by civil society and the tobacco industry. However, in Thailand the government sent mixed messages on its tobacco control position; the Thai Tobacco Monopoly under the Ministry of Finance promoted tobacco use, while the Ministry of Health worked to reduce its use. Similarly, in Botswana and Tanzania where the industry was protected and permitted to flout the anti-TAPS laws, the government sent mixed messages regarding their position on tobacco. These conflicting positions serve only to dilute the impact of anti-tobacco policies. ii) Anti-tobacco messages via mass media that are effective lead to increased awareness of the harms of tobacco use, reduces tobacco use and increase quit attempts. This is an efficient way,

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particularly for countries with high smoking rates where tobacco is culturally ingrained, to rapidly warn the public about the dangers of tobacco use. Turkey’s experience illustrates how social norms can be affected within a relatively short period of time by the effective promotion of anti-tobacco messages. iii) The use of graphic pictorial warning labels on cigarette packets is effective for informing or reminding smokers about the danger of tobacco use. Warning labels in Turkey were relatively new and very graphic; they were widely seen and successful in getting more smokers to think about quitting over time. However the older labels that Turkey had used in rotation for over five years were associated with a reduction in impact as fewer smokers over time were motivated by the labels to quit.

In many low and middle income countries where there are no policies requiring the use of pictorial warning labels, the widespread use of text warnings on imported cigarette packets poses barriers for those who speak different languages or are unable to read. It is imperative that all countries enforce policies requiring the use of graphic pictorial warning labels on cigarette packets as their intended messages are easily understood.

Here again it is important for international agencies and philanthropies to provide assistance for low and middle income countries to develop and implement policies that promote clear anti-tobacco messages. Technical assistance and resources should be made available to countries that need to implement mass media campaigns. Existing anti-tobacco campaigns and messaging may be shared across borders and within regions to the benefit of all. Assistance is needed especially among low income countries that rely on tobacco-related revenue to

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implement policies that would reduce tobacco dependency and effectively promote anti-tobacco messages.

5.4 Future Challenges for Global Tobacco Control in Low and Middle Income Countries

Although the vast majority of low and middle income countries have adopted the WHO

Framework Convention on Tobacco Control, the successful implementation of its provisions is far from adequate in many of these countries. There are many challenges, especially for low and middle income countries, that make the goal of controlling tobacco use a daunting task. The following issues are among the challenges to be addressed.

5.4.1 Politics

The disease and death that tobacco use causes is a public health issue, however, the fiscal benefits that tobacco use offers makes it a political issue. Governments, institutions and interest groups influence policy making and outcomes; thus the dichotomy between tobacco control for public health and tobacco promotion for revenue and profit produces competing interests.

The tobacco industry is the chief interest group that promotes tobacco use. Over the past decade, publicly traded tobacco companies have consolidated and now there are five major tobacco companies: Philip Morris International, Altria/Philip Morris USA, Japan Tobacco

International, British American Tobacco and Imperial Tobacco. In addition to these five corporations, there are 16 state owned tobacco companies (e.g. Thailand Tobacco Monopoly) that manufacture cigarettes in their own countries. It is estimated that the revenues from the global tobacco industry are about half a trillion dollars annually (Eriksen, 2012). In 2010 the combined profits of the top six companies was $35 billion (Eriksen, 2012). Philip Morris

International leads the cigarette market in volume of cigarettes and is the most profitable publicly

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traded tobacco company in the world (Atlas, 2013). According to the Altria website in 2011, “the

Altria Group has outperformed the Standard & Poor’s 500 stock market indices every year since

2000 and has increased its dividend 44 times in the last 42 years. Its scale, balance sheet strength and improved operational focus make the company a compelling consumer products investment opportunity, and enable the company to have large-scale economic impact” (Eriksen, 2012).

Naturally it is the goal of the tobacco industry to maintain or increase profit margins thus they seek to advocate for and promote tobacco use. Advocacy takes the form of influencing policymakers and other stakeholders to protect the industry’s interests. The WHO FCTC warns countries “to be alert to any efforts by the industry to undermine or subvert tobacco control efforts.” The industry’s contributions to politicians and to social causes are of great concern as they exert undue influence on decision making especially as it relates to tobacco regulations.

Given the scarcity of public health resources in low and middle income countries, it becomes an overwhelming challenge to match the effort and resources the industry spends influencing policymakers. However, as more research is focused on the economic and social toll of tobacco use and on successful cost-effective tobacco control interventions in low and middle income countries around the world, it may be possible to win the political support of governments and rally the activism of civil society to develop and enforce tobacco control policies that will save lives and emerging economies.

5.4.2 Resources

It can require considerable resource for countries to effectively implement tobacco control interventions such as mass media campaigns, surveillance systems, and the infrastructure to monitor and enforce anti-TAPS policies. The lack of resources, especially in low income

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countries, creates enormous challenges for governments with the political will to tackle the tobacco problem. This challenge is compounded for countries that have come to rely on the revenue generated by the manufacture, marketing and sale of tobacco. It becomes extremely difficult for them to give up the short-term financial benefits even though the long-term costs in lost productivity and premature deaths will be greater.

Since the ratification of the FCTC, the global impact of tobacco use has garnered the attention of international philanthropies – this is indeed an encouraging signal to low and middle income countries. Millions of dollars have been contributed by organizations such as Bloomberg

Philanthropies and the Bill and Melinda Gates Foundation to provide resources for tobacco control interventions globally.

In addition to financial resources, low and middle income countries require technical assistance and collaboration from across other governments and institutions to develop effective and efficient tobacco control programs and initiatives. Several non-governmental organizations such as, the American Cancer Society, Campaign for Tobacco-Free Kids, the International Union against Tuberculosis and Lung Disease, and the World Bank provide global tobacco control assistance. Institutions such as the World Health Organization and the Centers for Disease

Control and Prevention also play a significant role in providing technical assistance globally.

However, the need is great and public health resources are no match for the resources of the tobacco industry.

5.5 Future Research

There are a number areas related to this study that require additional research. Foremost, this study represents snapshots in time of the tobacco situation in a limited number of countries

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for which data are available. In time, social determinants and events will occur for better or worse that will change the tobacco use situation in low and middle income countries, therefore ongoing research and evaluation will be required to monitor the evolving state of tobacco control and its impact on public health.

More specifically, there are emerging issues relating to tobacco marketing that have not been addressed by policies in any country. For example, tobacco brands are increasingly being portrayed in movies produced in various parts of the world; public health advocates consider this to be a form of marketing. As foreign movies become more widely disseminated through various media, it becomes very difficult to regulate product placement bans across borders. Students in the countries studied were exposed to tobacco or smoking in film or videos at an extremely high rate. Some countries have tried to ban product placement in movies that are targeted to youth, however, additional research is needed on the success of reducing youth exposure to smoking in the media.

Additional qualitative research is needed to determine the social determinants of smoking for various groups within low and middle income populations. In certain African countries for example, smoking prevalence remains low although TAPS exposure is significant. Also, in

Thailand and Turkey female smoking prevalence has remained relatively low despite targeted industry advertising. Research to determine the factors that discourage tobacco use in some populations or make certain groups more susceptible would be helpful for future tobacco control initiatives.

As tobacco-related surveillance and research continues and expands among low and middle income countries, it will be possible to understand the nature and context of the problem

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and to determine solutions and best practices in tobacco control that may be widely shared and implemented.

5.6 Research Limitations

The limitations of this research include the fact that the number of countries included in the study was limited to those with repeated rounds of tobacco data. Additional data from more countries would strengthen the analyses and conclusions. As more data become available, future research will include additional countries and will address this issue.

In addition, the analyses were conducted on cross-sectional repeated survey data, unlike cohort data no causal links can be established between the variables studied. However the associations observed are consistent with the outcome of previous research that demonstrates causal links and is therefore helpful in developing public health policy recommendations.

Finally, the study was limited to two aspects of tobacco control policies – tobacco advertising, promotion and sponsorship and anti-tobacco messages. It was not possible to extrapolate the impact of these policies on smoking behavior from the impact of other tobacco control measures such as smoke-free policies or cigarette prices. However, the situational review by country showed no significant differences in the other tobacco control policies for the countries studied.

5.7 Summary

Tobacco use continues to be the leading cause of preventable death in the world. The

World Health Organization projects that by 2030 tobacco use will kill over 8 million people per year (WHO, 2013). A considerable shift in global smoking trends has occurred over the past few decades. Eighty percent of the world’s smokers now live in developing countries compared to

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20 percent in developed countries (WHO, 2013). This represents a striking reversal of the epidemic as smoking has declined significantly in developed countries and is now increasing in low and middle income countries.

One of the primary reasons for the increase in smoking in low and middle income countries is aggressive marketing of tobacco by the tobacco industry. Billions of dollars are spent annually to market tobacco through advertising, promotion and sponsorship. Cigarettes are one of the most heavily marketed products in the world; marketing methods include advertising through all forms of media; promotional activities such as price discounts, branded gift items or logo placements in movies; and sponsorships of events or community causes. The aim of cigarette marketing is to create a social norm wherein smoking is familiar, enjoyable and acceptable. Research shows that exposure to tobacco marketing increases tobacco use.

The WHO’s Framework Convention on Tobacco Control (FCTC) addresses tobacco marketing by calling for countries to avoid the effect of tobacco advertising, promotion and sponsorship by enacting comprehensive bans on all types of TAPS. Effective policies that prohibit TAPS are among the most powerful tools that countries can implement to protect their population from the danger of tobacco. Further the FCTC requires that countries warn the populations about the consequences of tobacco use by promoting and strengthening public awareness of tobacco control issues, using all available communication tools, as appropriate.

This research study suggests that there is an association between TAPS exposure and increased smoking and susceptibility for youth in low and middle income countries. This finding supports research previously conducted in high-income countries that demonstrate this association. Further it was found that strong anti-TAPS laws are associated with decreased

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student exposure to tobacco advertising and sponsorship, while weak anti-TAPS laws had no impact on the level of exposure to advertising and sponsorship in students. It was also suggestive of a relationship between the strength of anti-TAPS policies and smoking behavior; as smoking prevalence among students declined over time in African countries where strong anti-

TAPS policies had been implemented but increased over time in countries with weak anti-TAPS policies.

In addition, these findings demonstrate that effective enforcement of strong TAPS-related policies over time can result in improved tobacco control outcomes even in middle-income countries where smoking rates are high and tobacco use has been ingrained in the culture for decades. It is clear that ongoing progressive tobacco control efforts are required to maintain the impact of tobacco control policies over time as it is possible to reverse earlier achievements. It was also determined that the effective enforcement of anti-TAPS laws and anti-tobacco messages

(counter-advertising) can result in decreased exposure to TAPS and increased exposure to anti- tobacco messages. Finally, it was demonstrated that with adequate political will and support of civil society anti-TAPS policies can be effectively enforced and have an impact in a relatively short period of time.

The global effort to regulate tobacco marketing and warn populations about the dangers of smoking is a vital and effective component of tobacco control that must be adopted by all governments, including low and middle income countries. To quote Dr. Oleg Chestnov, the

Assistant Director-General of the WHO “We have the tools and we have the will. Millions of lives stand to be saved – we must act together and we must act now.”

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APENDICES A - E

APPENDIX A

Table A1: MPOWER Policy Interventions Ratings: TAPS Bans 2008 2009 2011 2013 Legislated Enforced Legislated Enforced Legislated Enforced Legislated Enforced Nigeria None ---- None ---- None ---- None ---- Uganda None ---- None ---- None ---- None ---- Botswana Strong 4/10 Strong NR* Weak NR Strong 4/10 Tanzania Weak 2/10 Weak 1/10 Weak NR Weak NR Kenya None --- Strong 6/10 Strong 6/10 Strong 6/10 Seychelles Moderate 10/10 Moderate NR Strong 10/10 Strong 10/10 South Strong 7/10 Strong 9/10 Strong 8/10 Strong 8/10 Africa *No Report Source: WHO Reports 2008; 2009; 2011; 2013

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Table A2: Thailand: Tobacco Control Progress Measures based on WHO MPOWER Ratings, 2008, 2009, 2011, 2013 2008 2009 2011 2013 MONITORING - Surveillance 10 7 10 10

PROTECT - Smoke-free Policy 0 3 10 10 - Compliance 0 6 6 6

OFFER - Cessation Treatment 4 7 7 10

WARNING - Labels 10 10 10 10 - Mass Media Campaigns -- -- 7 7

ENFORCE - Advertising Regulatory Policy 7 10 10 7 - Compliance 6 6 10 6

RAISE TAXES - Percent tax/price 10 8 8 8 Total Score 47 57 78 74 Possible Score 80 80 90 90 Final Rating (%) 59% 71% 87% 82%

Each item is scored between 0 and 10; based on WHO Global Tobacco Epidemic Reports: Summary Country MPOWER measure indicators and compliance ratings.

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Table A3: Turkey: Tobacco Control Progress Measures based on WHO MPOWER Ratings, 2008, 2009, 2011, 2013 2008 2009 2011 2013 MONITORING - Surveillance 10 7 10 10

PROTECT - Smoke-free Policy 0 10 10 10 - Compliance 0 6 10 10

OFFER - Cessation Treatment 0 4 10 10

WARNING - Labels 4 4 7 10 - Mass Media Campaigns -- -- 10 10

ENFORCE - Advertising Regulatory Policy 4 7 7 10 - Compliance 0 10 10 10

RAISE TAXES - Percent tax/price 5 8 10 10 Total Score 13 56 81 90 Possible Score 80 80 90 90 Final Rating (%) 16% 70% 90% 100%

Each item is scored between 0 and 10; based on WHO Global Tobacco Epidemic Reports: Summary Country MPOWER measure indicators and compliance ratings.

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APPENDIX B Table B1: GYTS Measures, Questions, and Recodes Variable Question Responses Recode Gender What is your sex Male 1= Male Female 2 =Female Age How old are you? >11 to 18+ 1= 13 years 2 =14 years 3 = 15 years Ever Smoked Have you ever tried or experimented with cigarette smoking, Tried smoking 1 = Yes even one or two puffs? 2 = No Current During the past 30 days, on how many days did you smoke Smoked ≥1 day within last 1 = Yes Smoker cigarettes? 30 days 2 = No Susceptibly to -If one of your best friends offered you a cigarette, would you 1= Definitely not 1 = Susceptible (2-4) smoking smoke it? 2= Probably not 2 =Non-susceptible (1) -At any time during the next 12 months do you think you will 3=Probably yes smoke a cigarette? 4=Definitely yes TAPS Advertising -During the past 30 days, how many cigarette advertisements 1 = a lot 1 = Exposed (1,2) have you seen on billboards? 2 = sometimes 2 = Not Exposed (3) -During the past 30 days, how many cigarette advertisements or 3 = none promotions have you seen in newspapers or magazines? Promotion -Do you have something (t-shirt, pen, backpack, etc.) with a 1= Yes 1= Yes cigarette brand logo on it? 2= No 2= No -Has a cigarette representative ever offered you a free cigarette? Sponsorship -During the past 30 days, when you watched TV sports events or 1= never watch TV, or 1 = Exposed (2,3) other programs how often did you see cigarette brand names? don’t go to events 2 = Not Exposed (1,4) -When you go to sports or community events, how often do you 2 = a lot see cigarette advertisements? 3 = sometimes 4 = never Attitude -Social norm -Do you think boys who smoke cigarettes have more or less 1 = more 1 = Positive (1,3) friends? 2 = less 2= Negative (2) -Do you think girls who smoke cigarettes have more or less 3 = same friends? -Does smoking cigarettes help people feel more or less comfortable at celebrations, parties, or in other social gatherings?

-Smoking cigarettes makes boys look more/less attractive? -Attractiveness 1=more/ 2=less/ 3=same 1 = Positive (1,3) -Smoking cigarettes makes girls look more or less attractive? 2= Negative (2)

-What do you think of a man you see smoking? 1-4 = Positive adjectives 1 = Positive (1-4) -What do you think of a woman you see smoking? 5-8 = Negative adjectives 2= Negative (5-8) Influence -Do your parents smoke? 1 = None; 2 = Both 1 = Yes (2 - 4) 3 = Father 4 = Mother 2 = No (1, 5) 5 = Don’t know -Do any of your closest friends smoke? 1 = None; 2 = Some 1 = Yes (2 - 4) 3 = Most 4 = All 2 = No (1) Smoking in -When you watch TV, videos, or movies, how often do you see 1= never watch TV, etc. 1 = Exposed (2,3) media actors smoking? 2 = a lot 2 = Not Exposed (1,4) 3 = sometimes 4 = never

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Table B2: GATS Measures, Questions, and Recodes Variable Question Responses Recode 1= Male Males Only Sex Gender by observation 1= Female

Age How old are you? 15+ 1= 15 – 24 2 =25 – 44 3 =45 – 64 4 = 65+

Tobacco Use How many kinds of tobacco products are you using every day or Cigarettes 1 = Yes

less than every day? Hand-rolled cigarettes 2 = No

Do you currently smoke tobacco? 1=daily 1 = Yes 2=less than daily 2 = No 3=not at all

Knowledge Based on what you know or believe does smoking cause serious 1=Yes 1=Yes illness? 2=No 2=No 3=Don’t know 3=Don’t know

Quitting Have you tried to quit using tobacco within the last 12 months? Smoked ≥1 day within last 1 = Yes Tobacco Use 30 days 2 = No

Intent to Quit Which of the following best describes your thinking on quitting 1= 1 month 1= within next 12 months tobacco use? “ I plan to quit within the next…” 2=12 months 2= not within next 12 mos. 3=12+ months 4= Don’t plan to quit

Counter Have you noticed any information describing dangers of 1=Newspapers/magazines 1 = Yes (1-5) Advertising smoking or encouraging giving up smoking in any of the 2=Television; 3=Radio 2 = No in Media following within the last 30 days? 4=Billboards; 5=Elsewhere

Counter Have you noticed health warnings on the cigarette packs within 1=Yes 1 = Yes Advertising on the last 30 days? 2=No 2 = No (2,3) packets 3=Not seen any packs

Impact of In the last 30 days, have warning labels on cigarette packages led 1=Yes 1 = Yes) counter you to think about quitting? 2=No 2 =No (2,3) advertising 3=Don’t know

Advertising Have you noticed any images, announcements, signboards or 1= Shops selling cigarettes 1= Exposed/Yes (1-10) adverts encouraging smoking in any of the following within the 2= Television; 3=Radio; 2= Not Exposed/No last 30 days? 4=Billboards; 5=Poster 6=Newspapers/magazines 7=Cinemas; 8=Internet 9=Mass transportation 10=Elsewhere

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Table B2 continued Variable Question Responses Recode Promotion Have you encountered any of the following situations 1=Yes 1 = Exposed (1) encouraging smoking within the last 30 days? 2=No 2 = Not Exposed (2,3) 3=Don’t know Or Have you noticed any of the following types of cigarette 1=Free cigarettes 1= Exposed (1-8) promotions? 2=Sale prices; 3=Coupons 2=Not exposed 4=Free gifts products 5=Clothing with logos 6=Mailed promotions 7=Internet promotions 8=Corporate social responsibility activities

Sponsorship Have you noticed any sports events that are associated with 1=Yes 1 = Exposed (1,) cigarette brands or firms within the last 30 days? 2=No 2= Not Exposed (2,3) 3=Don’t know

TURKEY i) In the last 30 days have you noticed any pictorial health 1=Yes 1 = Exposed/Yes (1) Country- warnings on cigarette packs? 2=No 2 = Not Exposed (2,3)

Specific 3= Not seen any packs

Questions ii) In the last 30 days have pictorial health warnings on cigarette 1=Yes 1 = Yes (1) packs led you to think about quitting? 2=No 2 = No (2,3) 3=Don’t know

iii) In the last 30 days did you see any video clips on TV that 1=Yes 1 = Yes (1) show patients talking about the harms of smoking? 2=No 2 = No (2,3)

3=Don’t know

iv) Did the video clips encourage you to think about quitting 1=Yes 1 = Yes (1) smoking?_ 2=No 2 = No (2,3) 3=Don’t know

THAILAND i) What brand did you buy the last time you purchased cigarettes List of popular brands. 1 = Domestic Country - for yourself? 2 = Imported Specific Questions ii) The last time you purchased cigarettes for yourself, did the 1=Yes 1 = Yes (1) cigarette package have a pictorial health warning? 2=No 2 = No (2,3) 3=Don’t know

iii) Do the health warnings on cigarette packages led you to try to 1=Yes a lot 1 = Yes (1,2) quit smoking? 2=Yes a little 2 = No (3) 3=Not at all

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APPENDIX C

TOBACCO ADVERTISING, PROMOTION AND SPONSORSHIP IN AFRICA

Tanzania – Billboard Advertising

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Points-of-Sale Advertising

189

Promotion – brand stretching

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Sponsorship – Social events

Corporate Responsibility Initiatives – University Scholarships

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Advertising targeting youth

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TAPS in Nigeria and Botswana

193

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Tobacco Promotion - South African Cigarette Girl

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Billboard Advertising

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APPENDIX D

POINT-OF-SALE ADVERTISING IN THAILAND

Point of Sale (POS) Advertising in Thailand

After the law requiring tobacco to be hidden Cabinet left open in violation of the law from view with sign “Tobacco Sold Here” Source: Fatal Attraction

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APPENDIX E

CIGARETTE WARNING LABELS

Cigarette warning labels in Thailand - Updated in 2013

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Warning labels in Thailand – 2007

Actual Cigarette Packs Thailand

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Cigarette Warning Labels in Turkey - 2008

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Cigarette Warning Labels in Turkey - 2008

Actual Cigarette Pack

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