CHAPTER II

REVIEW OF LITERATURE AND STUDIES

This chapter contains literature and studies regarding cigarette smoking, cigarette

smokers, and local and international studies about graphical health warnings in cigarette

packages.

Tobacco product is defined as any manufactured product made of leaf tobacco that is

used for smoking, sucking, chewing, or snuffing (WHO FCTC, 2005). There are three types of

tobacco preparation. The first one is the roll of tobacco which is smoked. Cigarette is the best

example of this. The second type is pipe like water pipes. The third is the oral preparation which

is chewed, held in mouth or placed in nose. Examples are snuff, snus, betel and quid (WHO,

2006). Tobacco contains nicotine and many carcinogens. Hence, it is an addictive plant (WHO,

2006 cited by Aguillon, J.M & Romano, P.B)

Philippine Cigarette Consumption

Cigarette smoking has long been viewed as an activity associated with men, at least in the

Philippine context. Recently, however, female smoking caught the interest of health advocates

due to the escalation in smoking incidences. Cigarette smoking is one of the country’s most

potent killers causing several diseases and causing people’s deaths regardless of age and sex.

According to Department of Health (DOH) Secretary Janette P. Loreto- Garin, stated that as

reported, about ten (10) Filipinos die every hour because of smoking (www.ntrc.gov.ph).

Filipinos mainly smoke cigarettes, which include manufactured cigarettes and hand-

rolled cigarettes (www.psa.gov.ph).

Based on the 8th National Nutrition Survey conducted by the Food and Nutrition

Research Institute (FNRI), smoking prevalence in the Philippines has gone down from 31% in

2008 to 25.4% in 2013; or specifically, from 53.2% in 2008 to 44.7% in 2013 in males, and from

12.9% to 7.8% in females (ntrc.gov.ph).

Compared to global average, however, male smoking incidence in the Philippines

exceeded the global average of 36% with smoking prevalence of 44.7% in 2013. The same is
also depicted for female smoking incidence at a higher rate of 7.8% against the global average of

7%. The smoking incidence of the total population was 25.4%, which was higher than the 21%

worldwide average. Nonetheless, in spite of these larger than normal figures, smoking incidence

in the Philippines declined in the five year period (NTRC Tax Research Journal, 2016).

A repository for the collection, analysis, validation and dissemination of all smoking and

health-related data was established by the World Health Organization. The data received from

various member countries were compiled into a book entitled Tobacco or Health: A Global

Status Report, 1997. This report showed smoking prevalence and other tobacco use-related data

from various countries and presented an analysis. It is estimated that there are approximately 1.1

billion smokers worldwide, of which 900 million are men and 200 million are women. The sex

ratio of men to women is 2:1 for developed nations and 7:1 for developing nations. Smoking

prevalence in men and women averages 42% and 24%, respectively, for developed countries,

and 48% and 7%, respectively, for less developed countries (www.ncbi.nlm.nih.gov).

In comparison, twenty-eight percent or 17.3 million Filipino adults age 15 years and

older are current tobacco smokers, according to the results of the 2009 Global Adult Tobacco

Survey (GATS). Almost half (48 percent or 14.6 million) of adult males and 9 percent (2.8

million) of adult females are current smokers. Moreover, 23 % of Filipino adults are daily

tobacco smokers: 38 % for males and 7 % for females. Cigarettes are smoked by 47 % of men

and by 9 % of women. On the average, male daily smokers consume 11 cigarettes per day while

female daily smokers consume 7 cigarettes per day (www.psa.gov.ph).

Social smoker - five or 10 cigarettes a week (Carey, B., 2000)

Perceptions and Attitudes towards Tobacco Smoking

Previous studies showed that knowledge of smoking health threats may vary across the

smokers’ ethnicity as well as educational level. Higher educational levels were related to higher

knowledge on smoking health risks (Ma, Tan, Freely &Thomas, 2002; Ma, Shive, Tan &

Toubbeh, 2002). Smokers with lower level of knowledge about the health dangers of smoking is
associated with their positive attitudes toward smoking (Shankar, Gutierrez, Mohamed, &

Alberg, 2000; Wiecha et al., 1998).

It was said that beliefs became part of a person’s system and these beliefs influenced the

person’s choices and behaviors. Occasional smokers do not smoke daily, or if they smoke they

smoke just a few. A study (Hammond, 2008) showed that most smokers perceive themselves

having lesser risk than other smokers.

Attitudes toward smoking are significantly associated with smoking status (Shankar,

Gutierre-Mohamed &Alberg, 2000; Marin, Marin, Perez, Stable ,Otero, Sabogal & Sabogal,

1990; Klesges, Somes, Pascale, Klesges, Murphy & Williams, 1988). Particularly current

smokers perceived smoking as having positive attributes while the non-smokers perceived

smoking as having negative characteristics (Taylor, Ross, Goldsmith, Zanna &Lock, 1998;

Shervington, 1994). Moreover, current smokers’ perceived susceptibilities of having smoking-

related diseases were lesser than the nonsmokers and former smokers even though the perceived

seriousness of all the groups was almost the same(Klesges, Somes, Pascale, Klesges, Murphy &

Williams,1988; Taylor,Ross,Goldsmith,Zanna&Lock,1998; Shervington,1994).

Non-smokers as well as those who quitted smoking had more negative perceptions

regarding smoking compared to smokers. Attitudes toward smoking are associated with socio-

demographics, educational levels, and ethnicity. Younger and more educated smokers perceived

smoking with higher personal risks of heart disease or cancers (Shankar, Gutierrez, Mohamed &

Alberg, 2000; Ma, Fang, Tan & Feeley,2003).

Causes of tobacco Smoking

Women and men have different psychological patterns that influence their behavior. The

same is evident in their motivation to smoke cigarette. Men are found to smoke when they are

experiencing positive emotions while women smoke to contradict any negative feelings they

harbor. Men are also more prone to smoke in public places with their peers, whereas women,

smoke in hidden places. Women are known to smoke to control weight and to relieve stress,

which may come from different pressing factors such as given related causes: strained family

relationships, peer pressure, poor religious background, etc. Men too, start smoking with similar
reasons in lesser frequencies. However, men tend to be more dependent on nicotine compared to

women, which is most likely the primary influencing factor on cigarette addiction for men. In

addition, men use cigarette as a social tool. Todd, et. al (1996) cited by NTRC Tax Research

Journal (2016), have concluded that role socialization and smoking have a complex relationship

where there are cases that socialization is used as means to get rid of stress.

Effects of Tobacco Smoking

Once thought to be relatively harmless and pushed as a 'past time' of sorts even by the

medical community, scientific studies have proved beyond a doubt that tobacco use – and

smoking, in particular – poses major health risks to humans (www.naturalnews.com).

Cigarettes are considered to be among the most deadly and addictive products made by

men. If the users will smoke cigarettes according to the intention of the cigarettes manufacturers,

cigarette smoking can kill half of its users (WHO, 2006 cited by Aguillon, J.M & Romano, P.B).

Scientific evidences show that the consumption and exposure to tobacco smoke cause

these three: (1) Death, (2) Disease, and (3) Disability. Aside from this, it has been found out that

there is a time interval between the exposure to smoking and the start of tobacco-related diseases

(WHO FCTC, 2005 cited by Aguillon, J.M & Romano, P.B).

As part of the Global Burden of Disease Study carried out by the Harvard University

School of Public Health in 1997, it was projected that mortality and morbidity from tobacco use

will increase by almost threefold worldwide in 20 to 25 years. Similar predictions have been

made by the Oxford University Center headed by Sir Richard Doll, who was one of the first

researchers to link cigarette smoking with lung cancer in the 1950s. Cancer, cardiovascular

diseases and chronic obstructive pulmonary disease continue to be the main health problems

associated with cigarette smoking (www.ncbi.nlm.nih.gov).

According to the Tobacco Atlas, the Philippines experienced 71, 850 tobacco-induced

deaths in 2010, which comprised 19.6% of deaths of men and 9.4% of deaths of women.
Congruent with smoking prevalence rates, more deaths occur in both men and women in the

Philippines compared with other middle income countries (NTRC Tax Research Journal, 2016).

Due to biological differences, some men and women smokers suffer distinct illnesses.

Risks in developing cervical cancer, breast cancer, ulcer and menstrual and pregnancy

complications are higher for female smokers than non-smokers. Men, on the other hand,

reportedly suffer from a decrease in sexual potency (NTRC Tax Research Journal, 2016). Other

than these, both men and women smokers are also at risks of the four main diseases generally

considered to dominate Non-Communicable Diseases (NCD) mortality and morbidity: (1)

cardiovascular diseases (including heart disease and stroke); (2) diabetes; (3) cancers; and (4)

chronic respiratory diseases, including chronic obstructive pulmonary disease (COPD) and

asthma. These four NCDs are caused, to a large extent, by four modifiable behavioral risk

factors: tobacco use, unhealthy diet, physical inactivity, and harmful use of alcohol (Department

of Health, 2011).

Among the identified risk factors contributing to NCDs, tobacco is considered

responsible for more than two-thirds of lung cancer, vesicle, esophagus, larynx, mouth and throat

(WHO, 2006 cited by Aguillon, J.M & Romano, P.B); 40% of chronic respiratory diseases,
emphysema and bronchitis (WHO, 2006 cited by Aguillon, J.M & Romano, P.B); and 10% of

cardiovascular diseases, stroke, heart attacks and other cardiovascular diseases (WHO, 2006

cited by Aguillon, J.M & Romano, P.B). An estimated six million people die from tobacco use

each year, causing nearly 10% of all deaths worldwide, two million more than AIDS, malaria,

and tuberculosis combined. (Department of Health, 2011).

Five out of ten leading causes of morbidity in the Philippines in 2009 and 2010 were

tobacco- attributable diseases, namely: Acute respiratory infection (1st), Acute Lower

Respiratory Tract Infection and Pneumonia (2nd), Bronchitis/Bronchiolitis (3rd in 2009 and 6th

in 2010) Hypertension (4th) and Respiratory Tuberculosis (8th). Smoking kills up to half of all

lifetime users. It is an epidemic that kills ten Filipinos every hour. Tobacco use was responsible

for over 58 thousands deaths or nearly 12% of all deaths in the Philippines in 2004, according to

the World Health Organization (WHO) calculations. Almost 80% of these deaths caused by

tobacco were among men. An estimated 6-8% of all deaths in the country are attributable to the

four tobacco-related diseases causing between 23,000-35,000 tobacco-related deaths per year

(Department of Health, 2011).

Tobacco-related diseases have been widely reviewed. According to WHO (2006) cited by

Aguillon, J.M & Romano, P.B):

It is now also known that tobacco use contributes to cataracts, pneumonia, acute myeloid

leukemia, abdominal aortic aneurysm, stomach cancer, pancreatic cancer, cervical cancer, kidney

cancer, periodontitis and other diseases. Tobacco seriously damages the reproductive system too,

contributing to miscarriage, premature delivery, low birth weight, sudden infant death and

pediatric diseases, such as attention hyperactivity deficit disorders. Babies born to women who

smoke are, on average, 200 grams lighter than babies born to comparable mothers who do not

smoke.

On the other hand, it’s not only the tobacco consumers who are susceptible to its negative

effects. The second-hand tobacco smoke which is also known as passive smoking has exposed

millions of people including half of the world’s children to the negative effects of tobacco

consumption. Evidences link second-hand smoking to the increased risk of cardiovascular

diseases, lung cancer and other cancer, asthma and other respiratory diseases, ear infection and

sudden infant death syndrome in children. The above mentioned diseases are but a few of

second-hand smoking’s harmful effects (WHO, 2006 cited by Aguillon, J.M & Romano, P.B).

The tobacco epidemic is rising rapidly hence the regulation of tobacco products is

critical. All tobacco products can cause disease and death aside from the fact that they are

harmful and addictive (WHO, 2006 cited by Aguillon, J.M & Romano, P.B)

Graphic Health Warnings

Graphic health warnings that depict the possible consequences of smoking are an

increasingly common feature of tobacco product packaging worldwide. Canada was the first

country to introduce graphic health warnings, replacing text-only health warnings in 2000, with

Brazil following in 2002. By February 2008, governments in Singapore, Jordan, Thailand,

Venezuela, Panama, Australia, Uruguay, Chile, Belgium, Hong Kong, Korea and New Zealand

had also introduced graphic health warnings, with many others considering or planning to do so

in the future (Elliot & Shanahan Research, 2008). Philippines have also implemented the graphic

health warnings and was approved on July 15, 2014 and took effect on August 7, 2014 (Official

Gazette of the republic of the Philippines, 2014)

This global phenomenon has been driven, to a large extent, by research that demonstrates

the effectiveness of graphic health warnings in increasing knowledge and awareness of the health

risks of smoking and in encouraging smoking cessation (Elliot & Shanahan Research, 2008).

Much of the research in the area is from Canada, where graphic health warnings appear to

have played a significant role in enhancing both smokers’ and non-smokers’ understanding of

the specific health consequences of smoking, motivating smokers to quit, discouraging relapse,

and deterring potential smokers from starting to smoke (Hammond et al, 2003; Hammond et al,

2004b cited by Elliot & Shanahan Research, 2008). The International Tobacco Control (ITC)

Project examines and compares the effect of various forms of packaging on smoker behaviours

and attitudes across a number of countries and demonstrates the greater effect of the graphic

health warnings compared to text-only warnings (Hammond et al, 2007 cited by Elliot &

Shanahan, 2008). Preliminary studies in Brazil, Singapore and Thailand indicate that graphic
health warnings have also had a positive impact on knowledge of smoking risks, and motivation

to quit (Datafolha Institute, 2002 cited by Elliot & Shanahan Research, 2008).

In essence, recent research continues to highlight the influence of a number of key factors

on the overall effectiveness of graphic health warnings on tobacco product packaging. The

importance of health warning noticeability, the presentation of motivating themes, message

clarity, credibility and reinforcement are emphasised throughout the literature. Significantly, past

research indicates that these factors must accommodate the varying ways in which specific

consumer groups respond to health warnings. Health warning relevance and variety are therefore

also notable. Finally, the introduction of plain packaging has also been raised in the literature as

a future measure that is likely to lend significant support to the impact of health warnings (Elliot

& Shanahan Research, 2008).

Republic Act 10643

All tobacco products are dangerous and addictive. Government effort should be made to

discourage the use of tobacco in any forms as well as to raise awareness about its harmful and

deadly effects. (WHO, 2006 cited by Aguillon, J.M & Romano, P.B). One government

intervention is the Republic Act 10643.

Republic Act No. 10643 (RA 10643) entitled “AN ACT TO EFFECTIVELY INSTILL

HEALTH CONSCIOUSNESS THROUGH GRAPHIC HEALTH WARNINGS ON TOBACCO

PRODUCTS” was approved on July 15, 2014 and took effect on August 7, 2014, fifteen (15)

days after its complete publication in newspapers of general circulation. (Official Gazette of the

Republic of the Philippines, 2014)

Implementing Rules and Regulations (IRR) of Republic Act 10643 according to the

Official Gazette of the Republic of the Philippines:

Purpose

These Rules are adopted to ensure the effective implementation of RA 10643 and

specifically to provide guidelines and procedures for compliance monitoring, reporting,

inspections, and enforcement; define the roles and responsibilities of implementing

agencies and all persons and entities involved in implementation; provide guidelines for

ensuring timely and strict compliance with the templates of the graphic health warnings

and guidelines on the use of such templates, and the ban on misleading descriptors;

provide guidelines to ensure that the graphic health warnings and the ban on misleading

descriptors promote the right to health and information of the people; and provide other

guidelines, procedures, and standards for the effective implementation of RA 10643.

General Provisions

A. Graphic Health Warnings on Principal Display Surfaces

All cigarette packages and other tobacco product packages, including

package inserts and onserts, and any outside packaging and labeling, withdrawn

from the manufacturing facilities or imported into the Philippine customs territory

shall bear Graphic Health Warnings on fifty percent (50%) of the lower portion of

the principal display areas or surfaces in accordance with the templates issued by

the DOH.

B. Additional Information on Side Panels

All cigarette packages and other tobacco product packages shall bear

additional information as prescribed by the DOH, namely additional health

warnings, hotlines or websites for tobacco-related concerns, or tips on how to stop

smoking, on an area of not more than thirty percent (30%) of the display surface

of one (1) side panel.

Mastercases, Inserts, Onserts and Outside Packaging and Labelling

A. Mastercases

Mastercases that contain the logo or trademark of tobacco brands shall

bear the textual warning “SMOKING KILLS”. The textual health warning shall

be printed in bold font, in the same single color as the trademark logo, and shall

occupy fifty percent (50%) of each principal display panel, with the purpose that

it shall be of equal prominence and visibility as the logo or trademark of tobacco

companies.

B. Inserts
 Graphic Health Warnings on inserts shall occupy fifty percent (50%) of

allsides or surfaceareasthat have any form of printing thereon.

C. Onserts

Graphic Health Warnings on onserts shall occupy fifty percent (50%) of

all sides or surfaceareas that may be displayed or visible under normal or

customary conditions of use; Provided, that the onserts shall be affixed in such a

manner that no part of the Graphic Health Warning printed thereon is obliterated,

obscured, folded, severed or unreadable.

No onserts shall be affixed or applied on a location where it is likely to

obscure or cover, in part or in whole, the Graphic Health Warnings or the location

where the internal revenue strip stamp is to be affixed as may be required by the

BIR.

D. Outside Packaging and Labeling

All outside packaging and labeling shall bear Graphic Health Warnings on

fifty percent (50%) of the principal display areas, in the same quality, color, and

proportion and in accordance with the templates issued by the DOH; Provided,

that for packages that have principal display areas that are disproportionate to the

specifications provided in the templates issued by the DOH, tobacco

manufacturers and distributors shall submit information on such outside

packaging and labelling, and the DOH shall issue further guidelines accordingly.

E. Reams/Cartons

a. Non-transparent reams/cartons

Non-transparent reams/cartons shall bear Graphic Health Warnings

on fifty percent (50%) of the principal display areas, in the same quality,

color, and proportion and in accordance with the templates issued by the

DOH.

b. Transparent reams/cartons

For reams/cartons that use transparent material on all principal

display surfaces such that all tobacco product package units are visible
 from outside, the packages shall be placed inside the ream/carton in such a

manner that the Graphic Health Warnings thereon are prominently

displayed and not obscured by any part of the packaging.

c. Partly-transparent reams/cartons

For reams/cartons that use transparent material on one (1) principal

display surface such that some tobacco product package units are visible

from outside, the packages that are visible shall be placed inside the

ream/carton in such a manner that the Graphic Health Warnings thereon

are prominently displayed and not obscured by any part of the packaging.

Such partly-transparent reams/cartons shall bear Graphic Health Warnings

on fifty percent (50%) of the non-transparent principal display surface, in

the same quality, color, and proportion and in accordance with the

templates issued by the DOH.

Specifications of Graphic Health Warnings and Additional Information

a. The graphic health warnings shall be printed in four colors /-cmyk-/ screen 133 lines

per inch based on a source file of 300 dpi. It shall be printed using current

available technology for purposes of providing vivid and realistic pictures, without the

use of any border, frame or any other design that will effectively lessen the size of the

warning;

b. The Graphic Health Warnings shall be printed or inscribed on the package in a color

which contrasts conspicuously with the background of the package or its labels;

c. The Graphic Health Warnings shall be reproduced in the same quality, color and

proportion as provided by the DOH in the templates or in the digital form, whichever is

clearer and more vivid, without modification;

d. The text warning accompanying the photographic picture warning shall be worded in

such manner that an ordinary layman will understand what the picture is about and what

the ill-effects of smoking are on the health of the smoker and on the people around him;

e. The text warning shall be placed on areas of the photograph where it will not obscure

the picture itself but will be prominently displayed;

f. The text shall use no more than twenty percent (20%) of the entire area of the Graphic

Health Warnings and shall appear in clearly legible type and in contrast by typograph,

layout and color, without the use of any border, frame or any other design that will

effectively lessen the size of the textual warning;

g. The accompanying text shall be printed in Filipino on the front panel and English on

the back panel. In the case of other containers where there is only one (1) external surface

area, the accompanying text will alternately be in English or Filipino; and

h. The additional information to be printed on the side panels of tobacco product

packaging shall be prominently displayed and the text thereto shall appear in clearly

legible type and in contrast by typograph, layout and color, without the use of border or

frame or any other design that will effectively lessen the size of the additional health

warnings.

Prohibition on Obscurement

Nothing shall be printed or applied on a location where it is likely to obscure or

cover, in part or in whole, the Graphic Health Warnings or the location where the internal

revenue strip stamp is to be affixed as may be required by the BIR. No part of the

warning may be obliterated, obscured, folded, severed or become unreadable when the

tobacco package is opened or closed or when a wrapper on the package is removed.

Issuance of Graphic Health Warning Templates

a. A maximum of twelve (12) templates of Graphic Health Warnings shall be printed

simultaneously and these shall be rotated periodically for each brand family and also for

each brand variant, so that every twenty-four (24) months, the variations of the warnings

shall appear in the market with approximately equal frequency and equal display of

health warnings and messages on retail packages.

b. Thirty days (30) days after the effectivity of RA 10643, the DOH shall issue a

maximum of twelve (12) templates of Graphic Health Warnings to be rotated, as well as

guidelines with respect to the specific pictures, design, or content of the information

relating to the Graphic Health Warnings, and other information that must appear on the

tobacco product packages.

c. The DOH shall consider the recommendations of leading nongovernment organizations

(NGOs) that have established and proven records of dealing with tobacco-related diseases

and deaths and that have no affiliation with the tobacco industry. All Graphic Health

Warnings issued shall comply with the specifications above and must always present the

devastating effects of tobacco use and exposure to tobacco smoke.

d. The initial set of templates is valid for two (2) years from implementation. Within one

(1) year from the effectively of the initial set of templates, the DOH shall issue a new set

of templates, which will take effect upon expiration of the initial set. These new

templates shall be valid for two (2) years and so on.

Ban on Misleading Descriptors

Beginning on [March 5, 2016],1no cigarette packs or other tobacco product

packages shall bear misleading descriptors or any number or descriptor such as “low tar”,

“light”, “ultra-light”, or “mild”, “extra”, “ultra”, and similar terms in any language that

claims or misleads a consumer to believe that a tobacco product, brand, brand family, or

brand variant is healthier, safer, or less harmful.

The date of publication of the Graphic Health Warning templates on March 4,

2015 shall be the reckoning period of the issuance of the initial set of templates for

purposes of complying with the timeline set by Section 8 of RA 10643.