Tobacco Control in the Philippines: The Enactment of the Graphic Health Warnings Law

INTRODUCTION

Tobacco use is one of the biggest public health threats in the world and the largest single cause of preventable deaths. Globally, it kills more than seven million a year with more than six million of those deaths attributable to direct tobacco use. Around 80% of smokers worldwide live in low- and middle-income countries such as the Philippines (World Health Organization [WHO], 2018).

In 2015, 23.8% of all Filipino adults reported current tobacco use in any form. Among daily cigarette smokers, the average monthly cigarette expenditure was PhP 678.4. About 95% of adults believed that smoking causes illnesses such as lung cancer, tuberculosis, heart attack, and stroke. Among current smokers, 76.7% planned to quit. Only 4%, however, successfully quit smoking (Department of Health [DOH] & Philippine Statistics Authority [PSA], 2015).

The Philippines started to implement tobacco control measures as early as 1987. Despite the strong lobbying of the tobacco industry, dubbed as the ‘strongest lobby in Asia’, the country has successfully passed Republic Act No. 9211 or “The Tobacco Regulation Act of 2003”. The Act was designed to promote a healthier environment and protect the citizens from the hazards of tobacco smoke by (a) informing the public of tobacco-related health risks, (b) banning tobacco advertisement and sponsorship except at point-of-sale, and (c) imposing textual warnings on tobacco packages.

In 2003, the Philippines became a State Party to the WHO Framework Convention on Tobacco Control (FCTC). The WHO FCTC is an evidence-based public health treaty that reaffirms the right of the people to the highest standards of health. It represents a paradigm shift in developing tobacco regulatory strategies and asserts the importance of demand reduction strategies (WHO, 2003).

The core demand reduction provisions in the WHO FCTC include price and tax measures to reduce the demand for tobacco. Non-price measures include protection from exposure to tobacco smoke; regulation of tobacco product disclosures, packaging and labelling; public awareness; among others. Regulations on illicit trade and sales to and by minors, and provision of support for economically viable alternative activities compose the core supply reduction provisions of the FCTC (WHO, 2003).

In 2014, nine years after the ratification of the WHO FCTC by the Philippine Senate, Republic Act No. 10643 or “The Graphic Health Warnings Law” was signed into law by President Benigno Aquino III. The law mandates manufacturers and importers of tobacco products in the Philippines to include graphic health warnings on tobacco packages sold in the local market. It follows some of the major provisions stated in Article 11 of the FCTC.

This paper utilizes the Policy Analysis Triangle of Walt and Gibson (1994) in presenting the policy content, context, actors, and process of the Philippines’ tobacco control policy, particularly the Graphic Health Warnings Law.

CONTENT

Republic Act No. 10643, known as “The Graphic Health Warnings Law”, is a tobacco control policy of the Philippines that seeks to protect and promote the right to health of the people and to instill health consciousness through graphic health warnings (GHW) on tobacco products. The primary purposes of the Act include the following: (1) to have Graphic Health Warnings that effectively warn of the devastating effects of tobacco use and exposure to second hand smoke; (2) to remove misleading or deceptive numbers or descriptors like “low tar”, “light”, “ultra lights” or “mild” which convey or tend to convey that a product or variant is healthier, less harmful or safer; and (3) to further promote the right to health and information of the people.

The law, approved by President Benigno Aquino III in 2014, is applicable only to tobacco products that are locally manufactured or imported and sold in the Philippine market. It mandates the Department of Health (DOH) to issue a maximum of twelve highly visible full-color graphic health warning templates in a biennial basis which have two components: (a) a photographic picture warning and (b) an accompanying textual warning that is related to the picture. The graphic health warnings shall be printed to occupy 50% of the front and 50% of the back panels of the packaging and located at the lower portions of the panels or principal display areas of any cigarette package and other tobacco product packages.

Cigarette packages and other tobacco product packages will also bear on one side panel additional information such as hotlines or websites for tobacco-related concerns, tips on how to stop smoking, or other additional health warnings issued by the DOH. Tobacco manufacturers and companies are expected to use the 12 templates periodically for each brand and product variant.

Penalties for manufacturers, importers, and distributors of tobacco products for any violation of the law are the following:

  • On the first offense, a fine of not more than Five hundred thousand pesos (P500,000.00);
  • On the second offense, a fine not more than One million pesos (P1,000,000.00); and
  • On the third offense, a fine of not more than Two million pesos (P2,000,000.00) or imprisonment of not more than five (5) years, or both, at the discretion of the court: Provided, that the business permits and licenses, in the case of a business entity or establishment shall be revoked or cancelled.

Several government agencies are also given mandates for purposes of the implementation of this law. The Bureau of Internal Revenue (BIR) is mandated to ensure that cigarette stamps are not affixed on noncompliant packages. The Inter-Agency Committee on Tobacco (IAC-T) monitors overall compliance with the law while the Department of Trade and Industry (DTI) shall hear complaints of violation of this law filed by the IAC-T or any private citizen, corporation, or organization. Finally, the Department of Education (DepEd) is mandated to use the Graphic Health Warnings templates to educate children on the ill-effects of tobacco and ensure that these are included in relevant subjects under the K-12 curriculum.

ACTORS

In this paper, policy actors involved in the tobacco control saga in the Philippines are grouped into four: (a) government, (b) international organizations, (c) tobacco companies, and (d) advocacy groups.

The first group, government, includes all public officials or institutions that took part in the policy process. This includes the primary proponents namely, Senators Franklin Drilon, Pia Cayetano, and Paolo Benigno Aquino IV, and Representative Raul Daza. Other government actors include party-list and district representatives, the Inter-agency Committee on Tobacco, and the Department of Health, especially former Health Secretary Esperanza Cabral who was then a staunch advocate of graphic health warnings on cigarette products.

The second group, international organizations, include those that provide international data and information, benchmark, and policy direction in tobacco control. Institutions in this group include the World Health Organization (WHO) and the Southeast Asia Tobacco Control Alliance (SEATCA).

The third and probably one of the most influential policy actor is the group of tobacco companies that operate in the Philippines. Among them include companies that filed civil cases against the DOH such as Telengtan Brothers & Sons, Inc., Fortune Tobacco Corporation, and Mighty Corporation. Other members of the tobacco industry that influence tobacco regulations in the country include the government-recognized association of the industry, the Philippine Tobacco Institute, and the National Tobacco Administration.

Lastly, there are several anti-cigarette smoking groups or advocacy groups that expressed support behind the enactment of a law mandating graphic health warnings on cigarette products supporting the Sin Tax Law in achieving the goal of curbing tobacco use in the country. Such groups include non-government agencies (NGOs), civil society groups, professional societies, other members of the private sector, and the general public. Prominent civil society groups and professional societies involved in the GHW campaign include New Vois Association of the Philippines, Philippine College of Chest Physicians, Philippine Cancer Society, Framework Convention on Tobacco Control Alliance Philippines (FCAP), and Health Justice Philippines.

CONTEXT

The Philippines is one of the world’s most populous countries with an official population count of 100,981,437 based on the 2015 Census of Population (PSA, 2016). The total health expenditure per capita is at 3.7% as of 2015 (PSA, 2015).

The Philippines is one of the largest tobacco markets in the Asia Pacific Region with consumption of about 82 billion cigarette sticks. In 2005, the market share was dominated by Fortune Tobacco Corporation and Philip Morris Philippines Manufacturing, Inc. (SEATCA, 2008). The industry was estimated to have generated about 2 million jobs in 2002 and half of which involved marketing (SEATCA, 2008). Starting in 2007 until 2008, however, policies on tobacco advertising and sponsorship came into force.

Tobacco use and exposure to secondhand smoke (SHS) continue to pose a public health threat in the country. Among the countries in the Association of Southeast Asian Nations (ASEAN) in 2013, the Philippines ranked second in adult smoking incidence next to Indonesia (SEATCA, 2016). The Global Adult Tobacco Survey (GATS) conducted in the country in 2009 showed that about 17.3 million or 28.3% of population aged 15 years old and above in the Philippines smoked tobacco. Among the population, 29.8 million (48.8%) allowed smoking in their home and 6.1 million (36.9%) reported exposure to SHS in enclosed areas at their workplace (DOH & PSA, 2010).

On average, men smoked 11.3 cigarettes per day and women smoked 7.0 cigarettes per day. The mean average age of initiation of smoking among daily smokers aged 18-34 year was 17.4 years for men and 19.1 years for women. The average monthly cigarette expenditure among manufactured cigarette smokers in 2009 was PhP 326.4. An estimated PhP 148 billion or 1-2% of the country’s Gross Domestic Product (GDP) in 2009 was spent on health and economic costs due to tobacco-related diseases and death while the revenue from tobacco industry was about PhP 25.65 billion (DOH & PSA, 2010)

The tobacco epidemic kills more than seven million people a year. More than six million of those deaths are associated with direct tobacco use while around 890,000 are the result of exposure to second-hand smoke (WHO, 2018). In the Philippines, five of the ten leading causes of mortality can be attributed to smoking (DOH, 2013). Tobacco kills approximately 240 Filipinos every day or about 87,600 annually (DOH, 2012).

Republic Act No. 9211 (R.A. 9211) or The Tobacco Regulation Act of 2003 provides that smoking is absolutely prohibited in buildings and premises of all centers of youth activity, medical facilities, and other enclosed public spaces. In 2008, however, only two cities (Davao City & Makati City) were strictly enforcing smoke-free policies (SEATCA, 2008).

R.A. 9211 further states that all tobacco packages manufactured or imported in the Philippines and sold to consumers should bear a print health warning such as “GOVERNMENT WARNING: Cigarette smoking is dangerous to your health.” It required only four rotating text health warnings occupying the bottom 30% of the front panel of tobacco packages. The 2009 GATS showed that 90.6% of current cigarette smokers noticed these health warnings on their cigarette packages. However, only 38.2% thought of quitting because of seeing the warning label.

The WHO cites studies carried out after the implementation of pictorial package warnings in Brazil, Canada, Singapore and Thailand showing that pictorial warnings increase people’s awareness of the harms of tobacco use. As of 2014, picture-based health warnings are being successfully applied in over 70 countries worldwide (WHO, 2018).

Since 2004, tobacco companies in the Philippines have been manufacturing and exporting tobacco products with 50% picture-based health warnings (PHWs) to ASEAN countries but denying the Filipinos similar health warnings (SEATCA, 2008). Picture-based health warnings is a requirement stipulated in the WHO Framework Convention on Tobacco Control (FCTC), an international treaty initiated by the World Health Assembly. It is the first global agreement devoted to tobacco control to which the Philippines signed on September 2003 and ratified on June 2005. It mandates governments, within three years of entry into the agreement, to pass and implement a law requiring tobacco products to carry effective health warnings. The deadline for the Philippines came in September 2008. Both the House of Representatives and Senate failed to pass on time a legislation on graphic health warnings.

The Bloomberg Initiative to Reduce Tobacco Use was launched in 2006. The initiative seeks to strengthen tobacco control efforts to reduce the burden of tobacco in low- and middle-income countries by funding activities to promote freedom from smoking and reduce tobacco use. Some 23 grants with a total investment of US$ 4.9 million were awarded to government and non-government organizations in the Philippines (International Union Against Tuberculosis and Lung Disease & The Campaign for Tobacco-Free Kids, 2013).

In 2007, the DOH issued Administrative Order (A.O.) 2007-0004 or the National Tobacco Prevention and Control Program (NTPCP) that defined the roles and responsibilities on nationwide efforts on tobacco control of the different offices under DOH and of other departments. And in 2012, the DOH published the National Tobacco Control Strategy (2011-2016) with the structure and content of the plans being congruent with the strategic approach of the WHO FCTC.

PROCESS

Cognizant of the need to protect the Filipinos from the harm brought about by tobacco use, the 12th Congress of the Philippines and former President Gloria Macapagal-Arroyo approved and signed into law Republic Act No. 9211, otherwise known as “The Tobacco Regulation Act of 2003”. In the same year, the Philippines became signatory to the WHO Framework Convention on Tobacco Control. The FCTC, ratified by the Philippine Senate in 2005, obliged the government to comply with tobacco control standards and measures including the implementation of effective measures on packaging and labelling of tobacco products such as the adoption of graphic health warnings on tobacco packages.

This tobacco control measure was first introduced in the 14th Congress by Senator Aquilino Pimentel, Jr. and Representative Paul Daza. Both Bills require all cigarette packages and other tobacco product packages found in the Philippine market to bear picture-based health warnings. The house bill was met with strong opposition by lawmakers who were allegedly bribed to oppose the bill. It was subsequently rejected by the House Committee on Health on the basis of economic arguments affecting the livelihood of tobacco farmers. Due to this, the Philippines missed its September 2008 deadline for introducing more effective health warnings, including picture-based warnings.

Because of the Congress’ failure to pass this health measure, then Health Secretary Esperenza Cabral issued Administrative Order (AO) 2010-0013 in May 2010 to compel local cigarette manufacturers and importers to print graphic health warnings on tobacco products. It was met by five different lawsuits filed in five different local courts by tobacco companies asserting that the Order was unconstitutional and that the DOH didn’t have legal authority to issue the Order. The AO was first declared invalid by a court in Tanauan City, Batangas on February 2012.

In the 15th Congress, three house bills and a senate bill on picture-based health warnings were filed by Representatives Raul Daza, Teodorico Haresco, and Marcelino Teodoro, and Senator Pia Cayetano. All bills were not passed into law. Much of the focus of the nation back then was on another tobacco-related measure which is now known as the Sin Tax Law of 2012.

The year 2014 marked the sixth year that the Philippines has failed to meet its deadline. After many grueling debates, both the Senate and House of Representatives of the 16th Congress passed their versions of the graphic health warning bill on third and final reading on 9 June 2014. It was signed into law on July 2014 and took effect on March 2016 upon the release of the Implementing Rules and Regulations (IRR). By November 2016, eight months after the release of the IRR, all tobacco product packages sold and distributed in the country have had the prescribed graphic health warnings.

End note: This is a policy issue report submitted in partial fulfillment of the requirements for Health Policy Studies, UP College of Public Health

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