1

The International Tobacco Control Policy Evaluation Project: Evaluating the

Tobacco Control Policies of the Framework Convention on Tobacco Control

Geoffrey T. Fong, Ph.D.University of Waterloo, Canada

Jornadas Internacionales sobre Legislación para el Controldel Tabaco—Buenos Aires, Argentina—17 Aug 2005

Published on the Framework Convention Alliance Website, 24 Aug 2005:http://fctc.org/mercosurasociados05/program.php

2

“Tobacco is the most effective agent of death ever developed and deployed on a worldwide scale.”

– John Seffrin, President,American Cancer Society and UICC3rd Annual Canadian National ConferenceDecember 2002

3

Statistics on Global Tobacco Use

1.1 billion people smoke– 82% live in low-and middle-income countries– 500 million will die of tobacco-related causes

20th Century: 100 million tobacco-related deaths

21st Century: 1 billion tobacco-related deaths

5 million will die this year

By 2025: 10 million will die/year

Tobacco use is the number one preventable cause of death and disability in the world

4

What can we do?

Primary prevention at the population level: – Don’t just treat diseases; prevent the disease

– Do something that will affect the most people(reach)

– Do something that works! (effectiveness)

National-Level Policies

Population Impact = Reach x Effectiveness

What has the greatest potential impact in a country?

5

Framework Convention on Tobacco Control (FCTC)

First-ever international treaty on health

Adopted in May 2003

Ratified by 76 countries so far

Conference of the Parties: February 2006

6

Foreword:“The FCTC is an evidence-based treaty that reaffirms the

right of all people to the highest standard of health.”

IGWG-1 Summary of Discussion:“...there was a need for WHO support for national or

regional surveys in order to provide the evidence base for effective tobacco control strategies”

Preamble:“Determined to promote measures of tobacco control based

on current and relevant scientific, technical and economic considerations...”

The FCTC is an evidence-based treaty

7

Packaging and labelling (Article 11)—Warnings—Elimination of misleading descriptors (e.g., “light” “mild”)

Advertising, promotion, and sponsorship (Article 13)

Protection from exposure to tobacco smoke (Article 8)

Demand Reduction Provisions of the FCTC

Price and tax measures to reduce demand (Article 6)

Dependence and cessation (Article 14)

Education, communication, training, public awareness (Article 12)

8

The International Tobacco Control Policy Evaluation Project

8 countries so far:Canada United States Australia United KingdomIreland Thailand Malaysia Korea

Extensive surveys of national representative samples of adult smokers in each country– ITC Methods: as rigorous as the conditions will allow– Cohort survey: same individuals surveyed every year – Identical/similar methods across all countries– Identical and valid measures in all countries– Measures of the effects of each FCTC demand policy– Evaluation of FCTC policies at the individual level

9

ITC Research Team (so far)

CanadaGeoffrey T. FongMary E. ThompsonK. Stephen BrownSharon CampbellDavid HammondPaul W. McDonaldMark P. Zanna

United StatesK. Michael CummingsGary GiovinoAndrew HylandRichard O’ConnorFrank J. ChaloupkaFritz LauxHana Ross

AustraliaRon BorlandMohammad SiahpushMelanie WakefieldHua YongDavid Young

United KingdomGerard HastingsAnn McNeillSusan AndersonAnne Marie MackintoshFiona Harris

ThailandBuppha SirirassameeChanya SethaputAree ProhmmoPhilip GuestSteve HamannPrakit Vateesatogkit

MalaysiaMaizurah OmarFoong KinRahmat Awang

IrelandShane AllwrightLuke ClancyFenton HowellMaurice Mulcahy

KoreaHong Gwan SeoYoo-Seock Cheong

India (planning)Prabhat JhaPrakash Gupta

China (planning)Jiang Yuan

10

Representative national samples of adult smokers:– Canada, United States, United Kingdom, Australia– Each country: over 2,000 adult smokers randomly

selected

Telephone survey

Cohort survey: – Wave 1: October–December 2002– Wave 2: May–September 2003– Wave 3: June–December 2004– Survey conducted every year through 2009

ITC Project—Four-Country Survey

11

Warning Labels: Article 11 of the FCTCEvidence from the ITC Project

12

Warning Labels and the FCTC

Article 11—Warnings and messages:

– should be 50% or more of the principal display areas but shall be no less than 30%...

– may be in the form of or include pictures or pictograms

– shall contain information on relevant constituents and emissions

13

Why Warning Labels = An Excellent Intervention to Increase Health Knowledge

1. Frequency of exposure is highSmoker who smokes one pack a day (20 cigarettes):

20 x 365 = 7,300 possible exposures/year

2. Target audience is the desired audienceSmokers and those interested in smoking

3. Location and delivery is ideal:Exposure to the labels at the time of the purchaseExposure to the labels at the time of the behavior

4. Conclusion: strong potential to inform (smokers and non-smokers) of the impact of smoking

14

Smokers notice information on warning labels

88%

65% 64%56%

39%33%

25%

11%0

10

20

30

40

50

60

70

80

90

100

TV CigarettePacks

Print Poster Radio Leaflets Stores Internet

"Have you noticed information that talks about the dangers of smoking or encourages quitting…."

Yes

(%)

Smokers rank cigarette packs very highly as a source of information—and labels are very cost effective compared to television

15

Smokers learn about the harms of smoking from warning labels: strong evidence

SMOKING CAUSES … CAN AUS UK US

IMPOTENCE 60%

Canada was the only country whose warnings included information about tobacco use as a cause of impotence.

16

SMOKING CAUSES … CAN AUS UK US

IMPOTENCE 60% 36% 36% 34%

Canadian smokers are 2.68 (2.41–2.97) times more likely to believe that smoking causes impotence.

Similar enhancement of knowledge for other diseases and for smoke constituents (e.g., cyanide)

Smokers learn about the harms of smoking from warning labels: strong evidence

17

Warning Labels of the Four Countries(October 2002)

Canada Australia U.K. U.S.

1. Does warning label size matter?2. Are graphic elements better?

18

Label variables at Baseline (Oct-Dec 2002)

Outcome Measure Canada Aus. U.K. U.S.

Noticing labels often/very often 60 52 44 30

Reading labels often/very often 33 26 22 16

Labels are a motivation to quit 45 31 28 29

Labels have stopped you from having a cigarette 19 12 9 14

Pattern of results at baseline as would be expected from visual inspection of the labels—Canada is the leader

19

October 2002 May 2003

U.K.

Canada

Australia

U.S.

20

The enhancement of warning labels in the U.K. had a huge impact on labels salience/noticing, way above even Canada. But this is a measure of noticing, where mere novelty alone would be expected to have a huge effect

Enhancing warning labels increases label salience/noticing

21

Enhancing warning labels leads to greater likelihood of forgoing smoking a cigarette

Still a significant increase in U.K. compared to the other countries, but not above Canada at W2Evidence for limitation of effect of mere text/size enhancements relative to graphic elements.

22

Labels Make You More Likely to Quit Smoking

To what extent, if at all, have the warning labels made you more likely to quit smoking?

Canada Australia U.K. U.S.

Somewhat / A lot 29% 18% 27% 22%

Same pattern here for this question, asked only at W2: U.K. is significantly higher than Australia and U.S., but not quite as high as Canada.

23

Labels Make You Think About the Health Risks

How often, if at all, have the warning labels made youthink about the health risks of smoking?

Canada Australia U.K. U.S.

Somewhat/ A Lot 47% 33% 45% 33%

Same pattern here for this question, asked only at W2: U.K. is significantly higher than Australia and U.S., but not quite as high as Canada.

24

Implications for FCTC Implementation

Minimal Standard vs. Recommendations:

– should be 50% or more of the principal display areas but shall be no less than 30%...

– may be in the form of or include pictures or pictograms

should be

Results from the ITC Project suggest that countries who implement the FCTC label policy at its highest level will experience greater impact, compared to the minimal standard.

25

Labels may have greater impact in low-and middle-income countries

% Often or Very OftenHow often in the last 6 months have... ITC-SE Asia ITC 4-Country1. you noticed the health warnings

on cigarette packages?Malaysia = 53%Thailand = 62%

Canada = 60%, Australia = 52%United Kingdom = 44%United States = 30%

2. you read or looked closely at the health warnings on cigarette packages?

Malaysia = 38%Thailand = 44%

Canada = 33%, Australia = 26% United Kingdom = 22%United States = 16%

3. the warnings stopped you from having a cigarette when you were about to smoke one?

Malaysia = 28%Thailand = 36%

Canada = 19%, Australia = 12%United Kingdom = 9% United States = 14%

SE Asia: Higher levels of salience than even Canada. Labels may have greater impact in low/middle income countries (few other information sources).

26

Conclusions so far on warning labels

Warnings increase knowledge about health consequences of smoking

Warnings lead smokers to think about risks of smoking and to think about quitting

Change in warnings leads to increases in salience

Larger size is better; graphics are better

Warnings are linked to quitting, quit intentions

Don’t worry about negative reactions to warnings (e.g., avoidance)—they predict future quitting(Hammond et al., AJPH, 2004)

27

Argentina Warning

28

Uruguay Warning

29

Canadian Graphic Warning Labels

Introduced in 2001

16 graphic outside warnings—rotated

16 inside warnings—also rotated

30

Canadian Graphic Warning Labels

31

Canadian Graphic Warning Labels

32

Canadian Graphic Warning Labels

33

Second-Hand Smoke and Constituents

34

United States Canada

Visual Impact of the Canadian Warning Labels

35

Brazil

36

Other Graphic Warning Labels

EU/UK: ?

Thailand: March 2005 Australia: March 2006

37

The Effects of Banning “Light”, “Mild”, and other deceptive brand descriptors (Article 11)

Findings from the ITC Project

38

The FCTC and Deceptive Brand Descriptors

Article 11 of the FCTC calls for removal of “false, misleading, deceptive...” packaging and labelling...such as ‘low tar’, ‘light’, ‘ultra-light’, or ‘mild’”

Past research shows that such brand descriptors are indeed misleading:– Among adults (Kozlowski, Shiffman)– Among youth (Kropp & Halpern-Felsher; Fong et al.)– Youth who believed that “lights” are healthier than

“regular” cigarettes were more likely to progress in smoking 6 months later (OR=1.29, p=.04)(Elton-Marshall, Fong, & Zanna, 2005)

But what are the effects of banning these terms? Does a ban lead to a reduction of misperceptions?

39

ITC Evaluation of the EU Ban on “Light/Mild”

Ban went into effect on September 30, 2003 ITC Wave 1 to Wave 3: Significant reductions in misconceptions about “light” cigarettes in the U.K. compared to the other three countries:—“Light cigarettes are less harmful than regular cigarettes”

UK decline = 15% vs. average of 3% in the other three countries

—“Smokers of light cigarettes take in less tar than smokers of regular cigarettes.” UK decline = 18% vs. average of 6% in the other three countries

Banning “light/mild” decreases misconceptions about “light/mild” cigarettes

40

Conclusions about banning “light/mild”

ITC evaluation strongly supports bans: misperceptions were significantly reducedFCTC Article 11 is broad, calling for bans on “any means that are false, misleading, deceptive or likely to create an erroneous impression about its...health effects”Use the breadth of Article 11: Do NOT stop at “light/mild”. The industry has already switched in some countries (e.g., Brazil, U.K.) to other packaging and brand descriptors that similarly imply that they are less harmful (colours)Ultimate solution: plain packaging?

41

Conclusions about banning “light/mild”

Do NOT use ISO tar “ratings” to communicate with the public (e.g., Articles 10 and 12)– Very misleading: The ISO testing protocol is

conducted on a smoking machine that does NOT resemble real human smoking behavior

– Industry has used the ISO tar “ratings” to deceive the public and they are certain to devise methods for continuing to do so

– Implication: Use caution in implementing Article 10 (public disclosure of constituents) and Article 12 (educating the public)

42

The Effects of a Comprehensive Ban on Advertising and Promotion (Article 13)

Findings from the ITC Project

43

The tobacco industry claims that:– Advertising/promotion is not used to attract new smokers

(especially youth)– It’s just to get smokers to switch to their brands and to

keep their smokers from switching

This is untrue: – Industry documents: The industry has targeted youth in

the past and is continuing today wherever it can– Analyses of ad/promo expenditures vs. success in brand

switching: huge amount of money spent per switcher/retention.

Background on Advertising/Promotion

44

Comprehensive Ban on Advertising and Promotion in the U.K.

On February 14, 2003, these forms of advertising and promotion were prohibited:

• Billboards• Magazines and Newspapers• Direct Mail• Domestic Sponsorship (May 2003)• Website Advertising and Promotions• Exterior Signs in Store Windows

What are the effects of this comprehensive ban?

45

General Salience of Advertising/Promotion

Significantly greater decline in salience of tobacco messages in the U.K.

46

Advertising—Billboards/Posters and Newspapers and Magazines

Significantly greater decline in salience of tobacco messages in the U.K. in these venues

47

Promotion/Sponsorship: Sport/Sporting Event

Decline in U.K. and also in Canada becauseof Canada’s own sponsorship ban

48

Evaluation of U.K. Advert/Promo Ban:Summary of Findings

The comprehensive ban in the U.K. appears to be working: reductions in awareness of tobacco advertising and promotions were found just months after the ban was implemented

Supports the call for comprehensive bans in the FCTC

Important to have comprehensive bans– When bans are not comprehensive, industry shifts their

vast resources to channels not covered by a ban

– Research supports comprehensive bans

49

The Impact of Comprehensive Smoke-Free Legislation (Article 8):

Findings from the ITC-Ireland/UK Survey

50

Tobacco Smoke Pollution (TSP)—also known as Environmental Tobacco Smoke (ETS)

Scientific consensus that TSP (ETS):– is a known cause of cancers, cardiovascular

diseases, and respiratory diseases

Third leading cause of preventable death in the U.S., accounting for one death among non-smokers for every eight deaths among smokers (over 50,000/year in the U.S.).– This ratio is likely to be similar in South America

51

Alternatives Offered by the Industry and Allies

Ventilation does not work:– The level of ventilation necessary to remove TSP is

extraordinarily high. James Repace: would require “tornado-like winds” to achieve the level of air replacement necessary to remove TSP to “acceptable”(that is, de minimus risk) levels.

Designated smoking rooms/areas do not work:– Level of TSP within DSRs is extremely high

– TSP continues to seep into areas outside of the DSR

52

March 29, 2004: Ireland Goes Smoke-Free

Comprehensive smoke-free law

First country in the world to implement such comprehensive smoke-free workplace policies

– Included hospitality venues (bars, restaurants)– Few exemptions

Followed since by other countries (e.g., Norway, Sweden, Bhutan)

– Others (e.g., Italy) allow designated smoking rooms and/or other exemptions

The ITC Project conducted a national-level evaluation of the impact of the Irish law

53

International Tobacco Control Policy Evaluation Project: Ireland/UK Survey

Telephone Survey– Ireland: 1,000 randomly selected adult smokers– U.K.: 600 randomly selected adult smokers– Cohort design:

Wave 1: Dec 2003–Jan 2004Workplace Ban: Mar 29, 2004Wave 2: Dec 2004–Jan 2005

54

Point Prevalence of Smoking in Key Venues

“The last time you visited a [venue], was there smoking inside?” Yes or No

– Drinking establishments (bars and pubs)– Restaurants and cafés– Public buses– Enclosed shopping centres/malls

Workplace: “in the last month, have people smoked in indoor areas where you work?”

Representative sample of venues in each countryWhat was the effect of the Irish smoke-free law on smoking in key public venues?

55

56

57

58

Other ITC findings showing that the Irish law reduced tobacco smoke pollution

94% of Irish smokers reported that pubs were enforcing the law “totally”

98% of Irish smokers (vs. 35% of UK smokers) said that there was less smoke in pubs than one year ago

Conclusions:1. The smoke-free law led to near-total

elimination of smoking in key public venues in Ireland (especially in pubs)

2. A very high proportion of U.K. workers continue to be exposed to tobacco smoke

59

Smoke-free pubs lead to smoke-filled homes?

John Reid, former U.K. Secretary of State for Health, at a House of Commons Health Committee Evidence Hearing, Feb. 23, 2005:

In Scotland, for instance, they have decided to go for a complete ban on smoking. I came to the conclusion that that was not a good thing on health grounds, apart from anything else, because you get a displacement of smoking from some public areas to the home - and most of the evidence about passive smoking is about the home...

...what we do know, for instance in Ireland and we would anticipate in Scotland, is that a percentage of people who previously went to the pub to smoke will now get a carry-out and take it home. I think the percentage in Ireland is about 15 per cent.

60

Proportion of homes allowing smoking has decreased in Ireland since the ban (p=.002)

61

Support for Smoke-Free Law Among Smokers

Important barrier to policy: Policymakers believe that smokers would not support a smoke-free law.

Studies show that:1. Support among smokers is lower than among

non-smokers (obvious)2. Support for smoke-free laws in bars/pubs is lowest

How did support among Irish smokers change after the implementation of the law?

62

63

64

65

Reported Effects on Quitting

79% of Irish smokers who reported quitting at Wave 2 say that the smoke-free law made them more likely to quit;

90% stated that the law helped them stay quit

46% of Irish smokers who reported still smoking at Wave 2 say that the law made them more likely to quit

ITC results consistent with an important literature review: Fichtenberg CM, Glantz SA. Effect of smoke-free workplaces on smoking behaviour: systematic review. BMJ 2002; 325(7357):188

66

Economic Impact of Smoke-Free Laws

Reviews of economic impact: smoke-free laws have either no effect or a slight positive effect on the hospitality trade.– Important review: Scollo M, Lal A, Hyland A, Glantz S.

Review of the quality of studies on the economic effects of smoke-free policies on the hospitality industry. Tobacco Control 2003; 12: 13-20.

Economic impact has been either nil or positive in: California, New York City, Ottawa, Ireland

Important to look at research methods used (need control groups, need time trends before and after the implementation)

67

General Conclusions from ITC-Ireland/UK

The smoke-free workplace law in Ireland has been a public health success:

Compliance extremely high

Tobacco smoke: almost totally eliminated

Substantial increase in support among smokers

No evidence of shifting of smoking to private venues

Due to implementation of the law and the pre-implementation campaign

68

Ireland’s Legislation: Massive Cultural Shift

69

ITC Project—Current and Future Directions

Expansion to other countries– Korea– India– China– South American countries?

ITC International Tobacco Product Project– Evidence base for proper product regulation

70

SummaryFindings from the ITC Project provide the evidence base for FCTC policies. Specific recommendations:– Warning labels: go beyond the minimal standard– “Light/mild”: ban these and other deceptive

labelling and packaging: anticipate industry countermoves and implement broad legislation

– Advertising/Promotion: comprehensive bans– Smoke-free: comprehensive bans; avoid

alternative “solutions” (ventilation, DSRs)

ITC Project: evaluation/monitoring of FCTC (Article 20). Middle/South America: critical region

71

Summary

ITC Project: evaluation/monitoring of FCTC (Article 20). Middle/South America: critical region

We invite South American countries to join the ITC Project to contribute to the evidence base for the FCTC

72

International Tobacco Control Policy Evaluation Project

http: //www.itcproject.org

Professor Geoffrey T. FongUniversity of Waterloogfong@uwaterloo.ca

73

Appendix A: More Information on “Light/Mild” Cigarettes

74

About “Light/Mild” Cigarettes

1950’s and 60’s: epidemiological studies and Wynder’s tar painting studies—cigarette tar level is associated with cancer. Implication: Low-tar cigarettes might reduce risk

BUT...“Light/mild” designation is artificial, and based on flawed ISO testing method

Industry documents: light/mild brands are marketed to appeal to health-conscious smokers—those who are thinking of quitting

The industry has deliberately designed cigarettes that deliver more toxins than implied by the ISO “tar ratings”

75

Why the ISO Testing Method is Invalid as a Method for Assessing Health Harm

The ISO/FTC protocol is set at much lower puff volumes and less frequent puffs than the average smokerTobacco companies have deliberately designed “light” brands to defeat the ISO smoking machine

Smokers compensate to get the nicotine dose they need (puffing harder/deeper; covering vent holes)Result: ISO ratings are invalid; “lights” are NOT less harmful

Filter vent holes let air through

Vent holes sit outside the ISO machine port so smoke is diluted

76

Deliberate deception of “lights”from BAT industry documents

The industry developed strategies to take advantage of the flawed ISO protocol. For BAT, the objective was, “...to produce a cigarette which can be machine smoked at a certain tar band, but which, in human hands, can exceed this tar banding.”

–Grieg CC BAT Southampton. Structured Creativity Group– Marketing Scenario. Undated. Brown & Williamson. Bates No. 650007446/7479.http://legacy.library.ucsf.edu/tid/dss00f00

Hammond, Collishaw, & Callard, Lancet, in press

77

Deliberate deception of “lights”from BAT industry documents

“The challenge would be to reduce the mainstream nicotine determined by the standard smoking machine measurement while increasing the amount that would actually be absorbed by the smoker.”

Blackman LCF. Research Conference Rio de Janeiro, Brazil 830822-830826. 9 Aug 1983. Brown & Williamson. Bates No. 512106879/6902.http://legacy.library.ucsf.edu/tid/hvx23f00

“We should strive to achieve this effect without appearing to have a cigarette that cheats the league table [of ISO tar yields]. Ideally it should appear to be no different from a normal cigarette...It should also be capable of delivering up to 100% more than its machine delivery.”

Brookes G. Proceedings of the Smoking Behaviour-Marketing Conference July 9th-12th 1984. Jul 1984. BAT. Bates No. 536000308/0356.http://www.library.ucsf.edu/tobacco/batco/html/14000/14028/index.html

Hammond, Collishaw, & Callard, Lancet, in press

78

Deliberate deception of “lights”from BAT industry documents

The industry wondered about the ethics of deliberately designing “low-tar” brands that delivered more tar and nicotine than the corresponding ISO ratings. These “elastic” brands (that is, those that increase the concentration of nicotine, andthus also tar, at higher levels of puffing) were being developed:“Is this an ethical thing to do? People who buy an 8 mg product expect to get 8 mg. . . .If a declaration that this product is elastic is made (which is the honest thing to do) then it could upset the apple cart.”

Creighton DE. Structured Creativity Group Presentation. 1984. BAT. Bates No. 100501696/1710.http://www.library.ucsf.edu/tobacco/batco/heml/5200/5266/index.html

In the end, of course, the industry kept this secret.Hammond, Collishaw, & Callard, Lancet, in press