The introduction of tobacco control to the policy agenda of the Philippines was influenced by both international and local contextual factors. Grindle and Thomas (as cited in Koduah, van Dijk, & Agyepong, 2015) described context as including the structure of society, historical experiences, economic and political conditions, as well as individual characteristics of policy actors. Kingdon (2014), on one hand, argued that policy actors and the processes by which agenda items surface into the political arena are key factors affecting policy agenda setting and choice. The processes by which agenda is set and choice is made are embedded within their context and thus, influence how actors work within these processes (Koduah et al., 2015).
Contextual factors that shaped tobacco control policies in the Philippines include the tobacco industry’s political and economic influence, economic conditions of the country, pressure from advocacy or interest groups, international agendas and treaties, and health-related outcomes. These factors eventually served as sources of power that actors used to influence the policy process, and to justify their actions and/or inactions.
In presenting the policy context of the GHW, this paper utilizes the Leichter model which categorizes context into situational, structural, cultural, and international or exogenous factors. It is acknowledged that this model has limitations but it offers guidance on systematically presenting policy context.
International / Exogenous Factors
The WHO is considered an international agenda setter when it introduced the Framework Convention on Tobacco Control (FCTC). The FCTC, as an international treaty, set the world’s policy agenda on tobacco control. Hence, it became the Philippines’ duty to enact policies on tobacco control including graphic health warnings on tobacco packages. It has acquired political support because it provided evidence-based measures and standards to curb tobacco consumption. The FCTC provided the basic guidelines from which the Philippines’ GHW law was derived.
Reports from nationwide and global surveys provide facts related to smoking prevalence and practices among Filipinos across age groups and sex. They provide a picture of the tobacco demand in the country and partly explains the booming tobacco industry. The 2009 Global Adult Tobacco Survey (GATS) showed that about 17.3 million Filipinos aged 15 years old and above smoked tobacco. The Global Youth Tobacco Survey (GYTS), on the other hand, reported that 13.7% of Filipinos aged 13 to 15 years old are using tobacco products (WHO, 2007).
The most influential promoting factors that advocates of the GHW policy pushed during the policy process are the health effects of tobacco use. 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). 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 (DOH & PSA, 2010).
In the Philippines, cigarette smoking presents a masculine appeal that encourages men to smoke. Smoking is also often associated with gender empowerment which drastically changed the views of women on smoking hence, increasing the female smoking prevalence. On average, men smoked 11.3 cigarettes per day and women smoked 7.0 cigarettes per day (DOH & PSA, 2010). Among the youth, peers provide the notion that smoking is “cool” and a perception that tobacco use will increase their social acceptance thus, providing a sense of belonging to a sought-after peer group (Choe & Raymundo, 2001). The mean average age of initiation of smoking among daily smokers was 17.4 years for men and 19.1 years for women (DOH & PSA, 2010).
Another promoting factor is the evidence supporting the claim that text health warnings on cigarette products are not enough to convey the harmful effects of smoking especially to those unable to read. The 2009 GATS showed that 90.6% of current cigarette smokers noticed these text health warnings on their cigarette packages. However, only 38.2% thought of quitting because of seeing the warning label.
The Philippines was once called as having a “sachet economy” as it allows a consumer in making smaller cash outlays for smaller packages. Most Filipino smokers resort to buying one or two sticks at a time with an accompanying free light-up service from the vendor instead of buying a pack of cigarettes. The culture of single-use buying in the country has affected the implementation of health warnings on tobacco packages.
With the end goal of effectively instilling health consciousness and deterring potential smokers, the GHWs on tobacco product packages were introduced to deliberately present the harmful effects of tobacco use and to change the wrongful notions associated with smoking.
The Philippines is one of the largest tobacco markets in the Asia Pacific Region. Data from the National Tobacco Administration (NTA) show that a total of 48,179,168.01 kilos of locally grown tobacco with a farm-gate value of PhP 3,645,382.92 was purchased by 36 NTA-registered trading centers in 2017. Majority of tobacco leaves were harvested from Cagayan Valley and the Ilocos Region. In the same year, NTA estimated a total of 2,772,715 employees and dependents of the tobacco industry making it one of the biggest industries in the country. The tobacco industry posits the advantage of a growing tobacco industry as having significant contributions to the Philippine economy. These economic assumptions were often used to counter health-related arguments putting revenue above health in the discussion.
In anticipation of stricter tobacco control policies resulting from the FCTC, tobacco companies were able to get Congress to pass Republic Act 9211 or the Tobacco Regulation Act of 2003, a “weak” law on tobacco consumption, advertising bans, and tax increases. It can be said that a window of opportunity partially opened which eventually led anti-tobacco advocates to support the law since it was perceived to be better than not having anything at all (Newsbreak, 2006). The law only required text warnings on the side panel of cigarette packs from January 1, 2004 to June 30, 2006 and on 30% of the pack’s front panel starting July 1, 2006. This demonstrated the power of the tobacco companies to enjoy undue and unregulated influence over policies affecting their industry.
In response to the Congress’ failure to pass a GHW policy, DOH issued Administrative Order (AO) 2010-0013 compelling local cigarette manufacturers and importers to print graphic health warnings on tobacco products. It was met by five different lawsuits by tobacco companies asserting that the Order was unconstitutional and that the DOH didn’t have legal authority to issue the Order. 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. Together with the FCTC, these precedent policies supported the passage of the GHW law and were used to build on other policies to address the tobacco epidemic.
Impact and Implications to the Policy Process
Policy Issue Identification & Recognition
Policy actors, especially the agenda setters, worked along interconnected contextual factors which acted as constraints or opportunities to influence the policy agenda and content. Since 2003, health warning on tobacco products has managed to remain on the country’s policy agenda. However, it has remained dormant for more than a decade stemming from major influences of context and policy actors. Contextual factors that influenced the ebbs and flows of the policy include the country’s political climate, perceived economic effects of the measure, health and demographic indicators, and international agenda. These factors served as a source of power for policy actors to (1) influence the inclusion of GHW as a policy agenda item, and (2) justify their actions, inactions, and choices.
Tobacco companies used economic arguments to counter the GHW policy. They managed to convince the government to side with the tobacco industry for the economic benefits it will get from producing and manufacturing tobacco products, and to blatantly disregard the State’s responsibility to control tobacco consumption among its citizens. The policy failed multiple times to put itself among priority items in the government’s policy agenda. Economic factors as contextual factors worked here as a constraint and provided other policy actors with conflicting options that directed the policy process in favor of the tobacco industry’s interests.
Aside from contextual factors serving as a source of power, policy actors also has power by virtue of their knowledge, experience, and political will which was critical in the decisions made for or against the policy. The emergence of leaders from the House of Representatives and Senate, acknowledged as policy champions, provided direction to the policy process. Local and international anti-tobacco groups were effective coordinating mechanisms which mobilized various stakeholders to address the issue. They became active agenda setters even when some of them did not have official government positions to make and implement public policies. Due to persistence of and pressure from these anti-tobacco groups and policy champions, the policy remained in the policy agenda of the Philippines.
Three characteristics of the issue have made it appealing to policy actors: the presence of credible indicators, burden relative to other existing problems, and an effective intervention or solution. Health indicators proving the effects of tobacco consumption on health outcomes served as a powerful promoting contextual factor.
Policy actors also relied on empirical evidence to inform their decisions during policy formulation. National and international surveys revealed the ineffectiveness of written health warnings in discouraging the youth to smoke, or even lessening the consumption of current tobacco smokers. On the other hand, studies presented by WHO proving the effectiveness of an inexpensive, simple, and evidence-based alternative – graphic health warnings – set the course of the policy in the Philippines.
Some of the contextual factors presented above worked together as an opportunity which presented policy agenda setters with options in shaping the policy. Shiffman and Smith (2007) categorizes these contextual factors as issue characteristics which, in this policy, were used as ideas and power to frame the policy issue in ways which those involved in the policy process understand or relate to. In particular, the GHW policy was framed as a health policy within the context of rising health costs and government expenditure, and increasing number of Filipinos dying of tobacco-related diseases. Framing it as a health policy attracted more policy actors into buying the GHW as a cost-effective solution to the burden of tobacco-related diseases.
The graphic health warning was first introduced in the 14th Congress by Senator Aquilino Pimentel, Jr. and Representative Paul Daza. Both Bills required all 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. 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.
In 2012, the 16th Congress passed a legislation raising sin taxes to increase government revenue that was mostly earmarked for health. Using Kingdon’s multiple streams framework, one can say that the passage of the Sin Tax Reform Law in 2012 opened up a policy window and provided a political climate which was positive for policy change.
The policy window for the GHW law opened during the confluence of the streams: problem stream (recognition of the burden of tobacco-related diseases on the health of the population and economy of the country), policy stream (the introduction of an evidence-based tobacco control policy), and politics stream (commitment of policy champions in forwarding the policy issue). Using the various contextual factors as sources of power, anti-tobacco advocates strongly lobbied for a policy requiring graphic health warnings on tobacco packages – a health policy supporting the Sin Tax Reform Law in its goal of curbing tobacco consumption.
In 2014, Republic Act 10643 or the GHW Law was approved by then President Benigno Aquino III. The law follows most of the guidelines provided by the FCTC. However, it only requires tobacco manufacturers to print graphic health warnings on the lower 50% of the front and back panels of tobacco product packages instead of the top 50% layer of the panels. The tobacco industry is known to have lobbied all over the world to put the graphic health warnings at the bottom of the cigarette pack where it can be easily hidden or covered. Unfortunately, it was successful in the Philippines.
The tobacco industry’s powerful influence on the policy process also became apparent during the policy’s implementation. The law took effect on March 2016, two years after it was signed into law, where local and imported cigarettes started to be sold in packages with graphic health warnings. However, based on the law, the absolute prohibition on the retail sale of tobacco products without GHW started only on November 2016. Manufacturers and importers were given a year to print the graphic health warnings on tobacco packages and retailers have been given an additional eight months to exhaust stock with text warnings. Many anti-tobacco groups blame the powerful tobacco lobby for the delay. This further demonstrated the power of tobacco companies to influence not only policy formulation but also the implementation of the law. Coincidentally in 2014, the WHO released the Tobacco Industry Interference Index showing that the Philippines ranked third among countries with strong industry interference with a performance rating of 71 following Indonesia and Malaysia.
While many advocates laud the passage of the GHW as a tobacco control measure, much has to be done in its effective implementation. The policy partly addresses the issue on tobacco control, however, it lacks the ability to fully change several mental models (i.e. smoking is cool & masculine) that could drive or deter the implementation of the policy. A recent study showed that 73% of smokers relied on television to learn about tobacco-related diseases. The use of GHW may only serve its purpose to a few smokers knowing the fact that most of these smokers actually rely for information through other media. Lastly, only about 20% buy cigarettes per pack (versus 80% buying per stick) making it difficult to ascertain the effectiveness of GHW on tobacco packages in changing the tobacco landscape of the country.
Policy context does not only influence the type of stakeholders that get involved in the process. It also gives the stakeholders the power to influence the policy process. The ability to use contextual factors as power and influence are often affected by their resources, privileges, and political power.
There is said to be a two-way relationship between policy makers and stakeholders. The latter are often asked to contribute inputs to policy formulation. As in the case of the GHW policy process, health advocates were able to use empirical data not just to influence policy agenda setting but also to help shape the policy. For instance, the DOH together with other groups, used evidences to prove that placing a graphic health warning on the lower layer of tobacco packages is not as effective as placing it on the top layer where it cannot be easily obscured or hidden.
Stakeholders’ response to a policy’s contextual factors vary depending on individual perceptions, experience and priorities. Stakeholders then can become influencers within a specific context to affect the policy process.