successes stories (and challenges) in tobacco control from...

1

Successes stories (and challenges) in tobacco

control from Thailand

Prof.Dr. Prakit Vathesatogkit, MD. FRCP

Advisor International Network for Health

Promotion Foundation

19 – 21 August ,2014

Bengaluru, India

Thailand’s Tobacco Control: Key Events (Before FCTC)

� 1989: Total Ban on Tobacco Advertising

� 1992: Tobacco Product Control Act

: Nonsmoker’s Health Protection Acts

� 1993: Implementation of Tax for Health Policy

(regular tax increase)

� 2001: Health Promotion Fund to fund tobacco

control and health promotion

2

3

The Tobacco Product Control Act 1992

� Ban sale to minors and by vending machines

� Total ban of advertising, promotion and

sponsorship

� Ban of free sample cigarettes

� Ban of small packets of cigarettes

� Health warning provision

� Ingredient disclosure

4

Smoke Free areas (1992-2004)

� Health Facilities

� Education facilities

� Religious places

� Air-conditioned restaurants

� Private office buildings

� Internet shops

� All Public transport

� Public parks

� Airports

� Sport arenas

� Government buildings

Certain designated smoking areas

5

Excise tax, cigarette sales and tax revenue

Year Tax Sales Tax revenue(%) (million Pack) (million of Baht)

� 1989 35-55 1,843 14,664 Start tobacco control

� 1990 55 1,941 15,461� 1991 55 1,942 15,898� 1992 55 1,983 15,438� 1993 55 2,135 15,345 � 1994 60 2,328 20,002 start tax for health policy

� 1995 62 2,171 20,736� 1996 68 2,463 24,092� 1997 68 2,415 29,755� 1999 70 1,810 26,708� 2000 71.5 1,826 28,110� 2001 75 1,727 29,627 Start health promotion fund

� 2002 75 1,716 31,247 Start UHI

� 2003 75 1,904 33,582� 2004 75 2,110 36,326

Source: the Excise Department, Ministry of Finance .Thailand

ASH THAILAND

6

1992 1997

25%

33%

The Quest for

a

sustainable funding for tobacco control & health promotion

7

• Two tobacco control law• Tobacco tax for health policy

Have in placed :

• Need funding to implement tobacco control program

Reasons for Thailand to set up a health promotion fund in the late 90’s

1. Unable to secure adequate budget for tobacco control purposes (for education, campaign, research, law enforcement) through regular channel.

2. There are other emerging non

communicable diseases facing

the same problem as with tobacco

control: no funding

8

Health financing reform policy (1996)MoF and MoPH

Appointed 2 Working Groups to Study:

1. Universal Health Insurance Coverage,

- to provide health security

2. Setting up Health Promotion Fund

- to prevent diseases/decrease health care cost.

This was advocated as a package

99

Result:

Two Complementary Acts Enacted10

Health Promotion Foundation Act 200111

� establishing Thaihealth Promotion Fund

administer by an autonomous state agency,

� Requiring extra 2% of alcohol and tobacco

surcharged taxes to this fund

� The funding is used for tobacco and alcohol

control programs as well as other health

promotion activities

12

12

2002 = 50 million USD

2013 = 130 million USD

13

Impact of Tobacco control measures in Thailand (1989-2004)

1993

1992- Tobacco Product

control Act- Smoke-free law

2011

Tax = 55% tax revenue 15,898

million baht

Sale = 1,941 million pack

Tax = 70%

tax revenue 57,196 million

baht


2003 ThaiHealth funding

2005- Graphic warning- Ban POS display- Ban CSR publicity

Population > 15 year = 38.3 million Population > 15 year = 53.9 million

Male = 59.3%Female = 4.9%


No of smokers = million

%

%

%

% % %

Krongtip = 12 baht Krongtip = 58 baht

2005FCTC

Ratification

Ban smoking in all public places

Smoking prevalence

Smoking prevalence

1991: Tobacco Control

Office

2003- Mass media campaign- Ban smoking in restaurant

1991 1996 2001 2004 2007 2009 2011

Annual

death from

tobacco

50,710

6 tax increases

In 15 years

- Smoking

prevalence

decease

- No Smoker

= 0.9 million

Tax revenue 36,326

million baht


Thailand’s early successes

� Push for policies & legislation, mainly through media advocacy & lobbying

� Work with limited budget (less than 300,000 USD annual)

� Lay down the “Best buy” intervention framework (tax increase / ad ban / smoke-free law & warning of danger)

� Established sustainable funding for tobacco control

14

15

Thaihealth’s funding led to many more players in tobacco control.

� Ministry of Health - policy development

� NGO - ASH , THPI - advocacy ,lobbying

- public awareness campaign

� Tobacco control Research center. Mahidol U.

� Health Professional Network

- smoke free health facility

- smoking cessation

� Teacher network - smoke free school

- smoking edu program

� National quitline

� Mass media campaign

� Community group

� Thai Health Promotion Foundation - funding to all party

On advertising / promotion / sponsorship : Thailand has ban

1. All form of advertising promotion and sponsorship including point of sale display of cigarette packet

2. Advertisement of CSR activities on TV and radio

3. Depiction of smoking on TV

4. Internet sale (administrative)

5. Implement movie rating system

16

Remaining FCTC(13) GAPs

1. Ban “CSR” publicity in print and other medias.

2. Ban CSR activities.

3. Cross border advertising

4. Legislation to ban internet sale,

5. Plain packaging legislation

6. Enforcement problems

17

18

1974

2004

1990

1992 19972009

50%

55%

On warning of danger :

19

-Toxic Chemical:

Carbon monoxide

Cyanide

-Cancer Causing

agents:

Formaldehyde

Tar

Nitrosamine

Labeling of toxic substances and cancer causing agent on side of packet 2007/2011

10 Rotating messages

MOH’s new regulation published in the Royal Gazette April 5, 2013

� Requiring 85% GHW on both principle

surfaces of cigarette packs

� Each carton must contain cigarette pack

with 10 different GHW

� Effective date October 2, 2013 (6 months)

20

Effective October 2, 2013

Thailand’s MOH new regulation

ASH Thailand21

BRANDBRAND BRANDBRAND BRANDBRANDBRANDBRAND BRANDBRAND

BRANDBRAND BRANDBRAND BRANDBRAND BRANDBRAND BRANDBRAND

BRANDBRAND

Each carton must contain cigarette pack with

10 different GHWASH Thailand

22

Tobacco industries filed lawsuit

against MOH

� JTI filed suit : June 20, 2013

� PMI filed suit: June 26,2013

� TTTA and two smokers filed suit: July 5, 2013

� BAT filed suit: August 1, 2013

Request for1. Court injunction (stay order)

2. Rule that the law is illegal

23

Request Court to rule that the regulation is unlawful

1. The reg. is unconstitutional/unlawful

2. It violate the Trademark Act

3. It violate TRIPS Agreement

4. It is disproportionate

5. It create excessive burden

6. Technically impossible (10 pictures

per carton)

24

� The Central Administrative Court

issued “stay order” August 2013

� MOH appeal to high court

� The High Administrative court lifted

the “stay order” June 2014

� MOH will enforce the regulation September 23,2014

25

26

REPUBLIC OF KOREAREPUBLIC OF KOREACHINACHINA

Effective September 23, 2014

ThailandThailand

27

Regulation No 19 MOPH. June 28, 2010

Ban smoking

� Health Facilities

� Education facilities

� Religious places

� restaurants

� Private office buildings

� Government buildings

� Zoo

� Hotel lobby

� Internet shop

� All Public transport

� Public park

� All sport arena

� Night club and bar Non air con restaurants

� Open-air Market places

International Airport : only place with “Smoking room”

28

1992-1997

Cigarette smoke is harmful to people

close to you

2005-2012

Cigarette smoke kill near-by people

1989 - 1992

Respect the right of other by not smoking

in public places

Generating public support / compliance on smoke free law

Lady : “You don’t know me,

but why you are hurting me? (with your cigarette smoke)

Anti-Smoking TV Spot : Smoke free park

30

83.9 %

21.2 %

43.8 %

88.9 %

Exposure to second-hand smoke Comparison of the key finding (%)

2009 2011

Indoor workplaces 27.2 30.5

Healthcare facilities 4.8 7.3

Public transportation 21.6 25.6

Gov. Building 13.6 14.7

31

GATS Thailand 2011

Relying on self enforcing is not enough

Excise tax(%), cigarette sales, excise tax revenue

Year Excise Sales Excise Tax revenueTax (%) (million Pack) (million of Baht)

� 1993 55 2,135 15,345

� 1994 60 2,328 20,002

� 1997 68 2,415 29,755

� 1998 70 1,951 28,691

� 2004 75 2,110 36,326

� 2006 79 1,793 35,646

� 2007 80 1,958 41,528

� 2011 85 2,038 57,196

� 2013 87 2,172 67,863

Total tax burden to retail price = 70%

Cigarette sale volume/ Excise tax revenue

Mill

ion

Bah

t

Million BahtMillion Pack

Mill

ion

Pac

k

1992 2002 2012

33

Construction cost of MRT (Subway)

= 120,000 million Baht

Additional revenue gained from tobacco tax = 261,824 million baht (1994 – 2006)

Construction cost of sky train = 50,000 million Baht

34

Combine = 170,000 million baht

35

Rooms for improvement

1. tobacco tax structure

2. harmonization of taxes on

different tobacco products

3. indexation to inflation

4. strengthen tax administration5. strengthen illicit trade control

Impact of Tobacco control measures in Thailand (1991-2011)

1993

1992- Tobacco Product

control Act- Smoke-free law

2009


million baht



million baht


2003 ThaiHealth funding

2005- Graphic warning- Ban POS display- Ban CSR publicity

Population > 15 year = 38.3 million Population > 15 year = 53.9 million



If the rate of smoking in 2011 remain at 30% as in 1991,The number of smoker should be 17.2 million not 11.5 million. Thus the number of smoker in 2011 is 5.7 million less than it

should be.

No of smokers = million

%

%

%

% % %

Krongtip = 12 baht Krongtip = 58 baht

2005FCTC

Ratification

Ban smoking in all public places

Smoking prevalence

Smoking prevalence

1991: Tobacco Control

Office

2003- Mass media campaign- Ban smoking in restaurant

1991 1996 2001 2004 2007 2009 2011

Annual

death from

tobacco

42,000

Annual

death

from

tobacco

45,136

Annual

death from

tobacco

50,710

9 tax increases

37

Thaihealth funding for major NCDs risks reduction program

Issue based Million (USD)

2013 2014

Tobacco 8.0 11.8

Alcohol 10.7 9.3

Traffic accident 7.0 8.1

Physical activity 6.6 8.0

Diet/ Nutrition 5.0 6.8

Mass Media 7.8 7.0

Total 45.1 51.0

Assessed Plan

Investment

(million

$USD)

Outcomes

(million

$USD)

Social Return on

Investment

($ USD) Per $1

USD Investment

of ThaiHealth

1. Road Traffic Accidents

(2001-2010)48.5 6,312.0 130.2

2. Tobacco-Consumption

Control(2001-2010)47.8 876.3 18.3

38

Social Return on Investments of ThaiHealth

FCTC Article 26Financial resources (2004)

39

1. The Parties recognize the important role

that financial resources play in achieving the

objective of this Convention.

2. Each party shall provide financial support in

respect of its national activities intended to

achieve the objective of the Convention.

Obstacle for FCTC implementation Report from 126 Parties (2012)

1. Tobacco industry interference

2. Lack of political will

3. Insufficient level of financial support

for tobacco control

4. Lack of intersectoral coordination

40

Health Promotion Fund in WPRO country

Funding source

1. Vic Health Australia 1987 General budget

2. Health way Australia 1990 General budget

3. Singapore Health Promotion Board 2001 General budget

4. Mysihat (Malaysia) 2006 General budget

5. Tonga 2007 General budget

6. Mongolia 2007 Tobacco/alcohol tax

7. Republic of Korea 2011 General budget

8. Vietnam Tobacco Control Fund 2013 Tobacco tax

9. Laos Tobacco Control Fund 2013 Tobacco tax

41

WPRO started the “Prolead” project 2004

Health Promotion Fund in other region

Funding source

1. SwissHealth 1994 Health insurance

2. AustrianHealth 1998 %VAT

1. Thaihealth 2001 Tobacco/alcohol tax

2. Indonesia 2014 Tobacco tax

3. Nepal 2014 Tobacco tax

42

EURO

SEARO

SEARO is starting the “Prolead” project (2014)

43

Total tax rates levied by Parties on cigarettes by WHO region (% of average retail prices)

WHO region

Total tax rates levied by Parties on cigarettes (%)

Mean

African 55.5

Americas 57.9

South – East Asia 30.5

European 68.9

Eastern Mediterranean 49.8

Western Pacific 57.6

Global 59.4

FCTC Global Progress Report 2012

44

Mean average prices per pack of 20 cigarettes (US$) for different reporting periods, by WHO region.

WHO region

Mean average prices per pack of 20 cigarettes (US$)

2012

African 1.94

Americas 3.20

South – East Asia 0.79

European 5.87

Eastern Mediterranean 1.47

Western Pacific 5.54

Global 3.81

FCTC Global Progress Report 2012

45

A REPORT BY BILL GATES TO G20 LEADERS | Cannes Summit, November 2011

Mobilizing Domestic Resources

The World Health Organization (WHO)

recommends tobacco excise taxes of at least

70 percent of the pack price.

46

Failure to convince Gov to support Smoking Cessation:

Cessation therapy

• was given low priority, cessation

medication not cover by health insurance

• the most expensive and labour

intensive intervention in tobacco control

Thailand emphasis on changing the

environment (population base) rather than

dealing with individual smoker

Global NCD reduction targetsby 2025

1. 25% reduction in NCDs mortality

2. 30% reduction in smoking prevalence

3. 10% reduction in alcohol use

4. 30% reduction in salt intake

Tobacco control is most cost effective in reducing NCDs

48

Ischemic heart disease = 34,384

Stroke = 50,829

Cancer = 80,711

COPD = 18,660

DM = 26,380

Total major NCDs = 210,963

Total death = 415,900

Death from NCDs = 50.7%

Death from NCDs before 60 yrs. old = 27%

= 56,960

Not possible to fight NCDs without sustainable funding Thailand NCDs Death (2009)

What Thailand has gained from FCTC implementation

49

1. Stabilization of number of smokers (about 12 million)

2. Decrease smoking prevalence ( 59.3 40.7%)

3. Protection of million of Thai from second hand smoke

4. Government received huge amount of revenue from regular tax increase policy

5. Establishment of Thailand Health Promotion Fund to support NCDs control

6. Enhanced Universal Health Insurance coverage and quality of care.

50

Challenges1. Tax- High prevalence of hand roll cigarette (50%)

- excise tax structure – trading down effect

2. Smoke free law

- Weak enforcement

3. Marketing control

- Selling of single stick cigarette

- Violation of ad-ban

4. Tobacco industry interference

- Opposing government initiative

- CSR activities

5. Inadequate cessation support

6. Problem of new tobacco products

The way forward51

� Tobacco tax reform

� Include cessation services in UHI benefit.

� Strengthening of law enforcement

� Create tobacco control committee in provinces

� Incorporate FCTC provisions into related laws

� Increase tobacco control funding

� Ratification of Protocal to Eliminate Illicit Trade in Tobacco Products

successes stories (and challenges) in tobacco control from...

Documents