POLICY ANALYSIS REPORT: Graphic Health Warnings Law (Part 1)

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 (Department of Health [DOH] & Philippine Statistics Authority [PSA], 2015). According to the DOH, five of the ten leading causes of mortality can be attributed to smoking. Moreover, tobacco kills approximately 240 Filipinos every day or about 87,600 annually (DOH, 2012; DOH, 2013). An estimated Php 148 Billion or 1-2% of the country’s Gross Domestic Product (GDP) was spent on health and economic costs due to tobacco-related diseases and death in 2009 (DOH & PSA, 2010).

To address the growing tobacco epidemic, the Philippines started to implement tobacco control measures as early as 1987.  Several tobacco control legislations were passed to (1) increase tobacco taxes, (2) ban tobacco advertising or promotion, and (3) designate smoke-free places, among others.

According to the WHO, printing graphic health warnings (GHWs) on tobacco packages is a cost-effective means to increase public awareness about the dangers of tobacco use. Thus, protecting the people against the devastating economic and health effects of tobacco smoking. In 2014, Republic Act No. 10643, commonly known as “The Graphic Health Warnings Law”, was approved by then President Benigno Aquino III. The law mandates manufacturers and importers of tobacco products in the Philippines to provide health information by printing GHWs on tobacco packages sold in the local market. The said tobacco control policy seeks to curb tobacco use among current Filipino smokers and prevent smoking initiation among those who do not smoke, especially the youth.

This paper aims to present a policy analysis of R.A. No. 10643. To facilitate a systematic presentation, this policy analysis is structured according to the different stages of the policy process – from issue recognition to policy evaluation.

 

POLICY IDENTIFICATION AND ISSUE RECOGNITION

Agenda Setting

The Philippines is a tobacco growing nation. Much of the emphasis is placed on the economic contributions of the tobacco industry as reason to go against tobacco control. The key goal of tobacco control policies is to improve health. While the health arguments are beyond dispute, there is always a debate on the economic effects of tobacco control. Correcting market failures and reducing inequality are other important goals of tobacco control. The government, thus, carries the burden of balancing the health of its people and the potential economic gain from the tobacco industry. The present tobacco epidemic and conditions of the tobacco market provide substantial reasons as justification for tobacco control.

The Hall model of agenda setting is used to present how the issue got into the government’s policy agenda. This model argues that a policy issue only comes on the policy agenda when an issue and the possible solution are high in terms of their legitimacy, feasibility, and support.

 

Legitimacy

Many believe that smoking is a ‘sovereign choice’ made by a consumer who knows what is best for him or herself. Generally, people tend to act according to the perceived benefits and consequences of their actions. But people also tend to react to perceived risks by reducing risky behavior.

The economic assumption holds that if a smoker consumes tobacco with adequate information about its consequences and addictive property, and bears all costs and benefits of his/her choice, there will be no justification for government to intervene. However, this situation does not exist in relation to tobacco use. The tobacco market is often characterized by market failures – externalities and information asymmetry – that may justify government intervention on the grounds of inefficiency (Jha, Musgrove, Chaloupka, Yurekli, 2000).

External costs

Externalities, the costs imposed on people who do not choose to use tobacco products, is one aspect of failure in the tobacco market. The costs include short-term and long-term effects categorized into two: physical and financial. Physical externalities include health effects such as higher risk of disease or death. Financial externalities, on one hand, are costs that are imposed by smokers such as medical care costs.

Health care costs is one of the many costs attributable to tobacco use that are often shouldered by the government, as well as private individuals. In 2011, the Philippines lost Php188 billion to tobacco-related healthcare and productivity losses. In contrast, the Philippines earned only Php36 billion from the tobacco industry (HealthJustice, 2012).

 

Inadequate information about health consequences

Smokers are often not fully informed about health risks posed by tobacco use. There are still gaps in their understanding of the impact of tobacco on their health. Moreover, people generally tend to behave according to the perceived benefits and consequences of their actions. In the case of smokers, incomplete or inadequate information about the risks of tobacco smoking often leads poorly-informed smokers to underestimate the risks of their actions, and therefore behave in a manner that is opposite the situation when complete information is provided to them. Since people react to perceived risks by reducing risky behavior, a situation when there is incomplete information therefore means a world with higher smoking prevalence.

Why are smokers inadequately informed? Jha et al. (2000) describe two reasons why smokers tend to be ill informed. First, the tobacco industry does not provide these information, and sometimes, even hide or distort them. The tobacco industry does not have any incentive to provide health information that has the potential to reduce tobacco product consumption. It does not only hide information on the health effects of tobacco use, it also makes use of various means to advertise and promote its products as ‘safe’ and/or ‘healthy’ especially among the youth. Second, there is usually a long period between starting to smoke and the onset of illness. Such delay obscures the link between smoking and diseases unlike other risky behaviors where costs and benefits are usually immediately appreciated. It is also due to this time gap that the youth often cannot imagine and think of the future consequences of their behavior which makes it difficult to instill health consciousness among them. By the time they understand the health risks associated with smoking and are ready to quit smoking, addiction has taken hold.

 

Inadequate information about addiction

Smoking is both psychologically and physically addictive. More often than not, smokers do not understand the addictiveness of nicotine when they start smoking. Although some manage to quit, many others fail to succeed. The cost of quitting is high. Therefore, even with the intention to quit, some smokers continue to smoke because the costs of stopping the habit are greater than the costs of maintaining status quo.

Given inadequate information, young people often underestimate the risk of becoming addicted to smoking due to nicotine which relates to the underestimation of future costs and consequences from smoking. The notion that the youth will make unwise, uninformed decisions is recognized by the government and it is further affected by addiction and inadequate information. Nicotine addiction weakens the argument that smokers should exercise sovereignty. Thus, the government considers that the freedom of the youth to choose to become addicted should be restricted.

Given the myopic view of the youth on the ills of tobacco use, the inadequacy of information provided to all smokers, and the external costs imposed on others that result in premature death and illness, is it appropriate then for the government to intervene? The extent of failure in the tobacco market appropriately justifies government intervention through strategies including regulation, taxation, and information dissemination.

 

Feasibility

Cognizant of the need to protect the Filipinos from the harms 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” (Figure 1). One of the goals of the law is to bridge the gap between health information and the smoker, or the potential smoker, by requiring tobacco manufacturers and importers to provide health information through the use of text warnings on cigarette packs such as “GOVERNMENT WARNING: Cigarette smoking is dangerous to your health.” 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.

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Later on, through the Framework Convention on Tobacco Control (FCTC), the World Health Organization (WHO) presented studies proving the effectiveness of an inexpensive, simple, cost-effective alternative – graphic health warnings – which set the course of the policy in the Philippines. Global studies have shown that graphic health warnings prevented people from picking up the habit or continuing with it, a proof of the effectiveness of using the right kind of graphic health warnings. Recognizing  the ineffectiveness of written health warnings in discouraging the youth to smoke, or even lessening the consumption of current tobacco smokers, anti-tobacco advocates forwarded graphic health warnings as a new solution to the problem on information asymmetry.

The policy had a positive appeal to the public and to most national legislators because it does not pose any technological, financial, or workforce limitation and burden on the part of the government. The policy places the burden on the tobacco industry, the one responsible for printing the graphic health warnings on tobacco product packages.

Since 2004, tobacco companies in the Philippines have been manufacturing and exporting tobacco products with picture-based health warnings to ASEAN countries but denying the Filipinos similar health warnings (SEATCA, 2008). Marlboro and Mild Seven cigarette packs sold in Thailand have graphic health warnings occupying the upper 50% of both front and back panels of cigarette packages. These products were made in the Philippines by Philip Morris International and JT International. Thus, the law cannot be construed as a burdensome requirement on tobacco manufacturers as claimed by tobacco companies because they have adequately exhibited their capacity to print graphic health warnings on tobacco packages that are exported to other countries.

Support

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 warnings on tobacco products have 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 gain 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 were 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.

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).

Some of the grantees focused on introducing graphic health warnings into the policy agenda and encouraging the public and the policy makers to consider the policy measure (Table 1). These grants provided anti-tobacco groups with the capacity to influence the policy process, especially agenda setting, by increasing available resources, thereby increasing their power.

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Local and international anti-tobacco groups were also 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 on the policy agenda of the Philippines.

 

Confluence of streams and window of opportunity

The graphic health warning policy was first introduced in the 14th Congress by Senator Aquilino Pimentel, Jr. and Representative Paul Daza. At that time, only text warnings appeared on the bottom 30 percent of the principal display areas of tobacco product packages. 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 pro-industry lawmakers who blocked the bill from being discussed beyond the health committee claiming that the policy could kill the tobacco industry. After the bill passed four committee hearings, most of the congressmen who attended a technical working group meeting were allegedly bribed to oppose and kill the Bill.

In the subsequent 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 these bills were also not passed into law.

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: 30 percent in front (in addition to the existing 30 percent text-only warnings) and 60 percent at the back. 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.

Soon after the release of DOH AO 2010-0013, a change in leadership happened when the Aquino administration took the wheels of government fueled by a platform of good governance with emphasis on universal health care. This provided the opportunity for much needed tobacco control reforms.

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. This ended more than a decade-long process in which the problem stream, the policy stream, and the political stream were pulled together in a window of opportunity.

Stream Tamayo

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. The successful passage of the Sin Tax Reform Act of 2012 paved the way for advocates to strengthen their efforts to push for a law that was fully compliant with Article 11 of the FCTC.

Also, 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.

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