To analyze the process of policy formulation, the policy triangle framework of Walt and Gilson, which includes the policy context, content, process and actors, is applied.
The policy process of tobacco control in the Philippines was influenced by both international and local contextual factors. 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. The Leichter model is utilized in presenting these factors. It categorizes contextual factors into four categories: situational, structural, cultural, and international or exogenous. It is acknowledged that the model has limitations but it offers guidance on systematically presenting policy context.
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).
Smoking is not something that the public sees as a problem. A study showed that nearly one third did not see anything wrong about smoking. Many believed that it was part of a lifestyle, like a habit that may or may not be bad for them. It appears that most of the smoking public recognize the wrong in smoking yet it did not inflict enough fear to cause an urgency from them to stop or look at it negatively (Framework Convention on Tobacco Control Alliance Philippines [FCAP], 2008).
FCAP found that in 2008, current smokers were long-time smokers. Most of them have been smoking for more than five years while half have been smokers for more than 10 years. Majority of smokers started smoking during their teenage years. This tells us that it is critical to intervene during the early years of teenage life. The notion that smoking is part of lifestyle makes people more prone to take up the habit, especially the youth.
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 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.
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. It is the first global agreement devoted to tobacco control to which the Philippines signed on September 2003 and ratified on June 2005. 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.
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, the WHO presented studies from all over the world providing evidence on how large pictorial health warnings on tobacco product packages affect knowledge and behaviors. Studies done in Canada, Romania, United Kingdom, and Thailand showed that health warnings increase awareness of the health risks related to tobacco consumption. In particular, pictorial warnings were found more likely to be noticed and read than text-only warnings. Pictorial warnings including graphic fear-arousing information were found to be the most effective. Furthermore, pictorial warnings do not only decrease smoking uptake but were also found more likely to succeed in encouraging smokers to quit than text-only warnings. Providing a quit line number on tobacco packaging was also found to increase quit attempts (WHO, 2014).
The FCTC 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.
In 2013, given the global trend for more effective health warnings, pro-health legislators and policy champions pushed for graphic warnings on the upper 85 percent of the front and back of cigarette packages as recommended by anti-tobacco interest and pressure groups. The industry responded this time with its own GHW bill proposing only a 30 percent GHW on one side and a 30 percent text warning on the other side. A second alternate bill adding a text warning to the lower portion of the back panel in minimum compliance with the FCTC was also proposed by the tobacco industry.
Finally, on 15 July 2014, Republic Act 10643 or the GHW Law was approved by then President Benigno Aquino III. Guided by the principle that every person should be informed of the health consequences, addictive nature, and other threats posed by tobacco use and exposure to secondhand smoke, the Philippines has adopted a policy consistent with the provisions of the WHO FCTC, particularly the obligations stated under Article 11 of the Convention.
The primary purposes of R.A. No. 10643 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 is applicable only to tobacco products that are locally manufactured or imported and sold in the Philippine market. It mandates the 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 show the health dangers of tobacco use such as gangrene, emphysema, neck cancer, asthma, still & premature birth. 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 or principal display areas of tobacco product packages instead of the top 50% layer of the panels as recommended by the FCTC. 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.
Cigarette packages and other tobacco product packages will also bear 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 on an area of not more than 30% percent of the display surface on one (1) side panel. Tobacco manufacturers and companies are expected to use the 12 templates periodically for each brand and product variant.
The law also bans the use of misleading descriptors 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.
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.
How policy actors shaped the content
Stakeholders are actors that may have direct impact on a policy issue or indirectly affect it by strengthening or weakening the authority of policy makers and influencing the implementation process (Durham, Warner, Phengsavanh, Sychareun, Vongxay, Rickart, 2016). Understanding stakeholders’ perspectives do not only inform decision-makers in designing and implementing effective and sustainable policies but also assists in consensus building.
Key stakeholders who influenced the tobacco control policy process in the Philippines can be grouped into four: (1) government including the Department of Health (DOH), and national policy makers in the Congress; (2) several interest & anti-tobacco groups such as New Vois Association Philippines, Framework Convention on Tobacco Control Alliance Philippines, Philippine Cancer Society, and HealthJustice Philippines; (3) group of tobacco companies represented by the Philippine Tobacco Institute (PTI); and (4) international organizations such as the Southeast Asia Tobacco Control Alliance (SEATCA), and the World Health Organization (WHO). The policy makers are the key decision-makers, yet the influence of other opinion leaders such as SEATCA and DOH is also deemed significant.
All stakeholders appeared to be quite knowledgeable and expressed interest in the GHW policy. The majority of the stakeholders indicated their clear support for the policy. Anti-tobacco groups understand that the GHW law is a tobacco control measure that seeks to curb tobacco consumption and improve health outcomes among Filipinos by informing them of the dangers and health effects of tobacco use.
The Philippine Tobacco Institute (PTI) also have a good knowledge of the policy. However, it is often recognized as the primary opponent of tobacco control policies. As such, communicating or advocating the objectives and tenets of the country’s tobacco control policy could not possibly reduce its opposition.
Stakeholder power is the influence a stakeholder has over the policy – that is to either support or block the desired change. Most of the stakeholders were supportive of GHW as a tobacco control measure but their influence differed. WHO, an international stakeholder, had high power and therefore was in a position of great influence. It explicitly supported the policy. It was able to effectively mobilize its vast resources to forward the policy through the FCTC, as well as influence the policy process.
The DOH seemed ready to assume leadership role in this tobacco control policy. Some stakeholders perceive the DOH as having extensive power to help forward the policy and ensure its effective implementation. Interest groups, anti-tobacco groups, and the Department of Health (DOH) eventually established a support cluster or an advocacy coalition network.
Through the leadership of the DOH, this support cluster used their combined resources and power to affect the policy process primarily by framing GHW as a health policy through sector engagement, press releases, press briefings, and other activities using various media. Combining the resources of interest and/or anti-tobacco groups with the power of the DOH to influence the decision-making of policy makers was an effective strategy to forward their unified agenda.
Majority of these stakeholders support, in principle, the policy change. Stakeholder support is an important factor in determining the success of a policy intervention. The high level of support and agreement of international organizations, DOH and interest groups could be linked to the potential benefits of the policy. These benefits – decreased tobacco consumption and decreased morbidity & mortality of tobacco-related diseases – were all recognized and identified by these supportive stakeholders. However, stakeholder views differed with respect to the specific provisions of the law such as (1) size and placement of the graphic warning, and (2) preparation and adjustment period for tobacco product manufacturers and retailers.
Aside from the smaller GHW size, legislators were able to accommodate the following concessions following pressure from the tobacco industry:
- requiring the GHWs to be in the lower portion rather than the upper portion of principal display areas of packages as recommended by the WHO
- giving the tobacco industry a total of 20 months from publication of the initial set of the GHW for full compliance which is longer than the average implementation time (9 to 12 months) shown in previous studies, and
- requiring the Inter-Agency Committee-Tobacco (IAC-T), established by virtue of the Tobacco Regulation Act of 2003, to monitor compliance. The Philippine Tobacco Institute, lead organization representing the interests of the tobacco industry in the country, sits as a member of the IAC-T.
The tobacco industry was apparently unsatisfied with these concessions. The industry tried to weaken the implementing rules and regulations (IRR) by arguing for narrow interpretation of the law and pushed for excluding products in duty-free stores in the country. As a consequence, it took more than a year for the IRR to be finalized and released due to many instances of interference from the tobacco industry.
Framing and communication
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.
One key policy maker who hails from one of the tobacco-producing regions in the country has previously expressed concern about the effect of what he called the “burdensome requirement” on the tobacco industry which is a major revenue source of the government.
Another key policy maker, however, sided with the support cluster of DOH and anti-tobacco groups citing the economic cost of smoking and the potential positive effects of tobacco control to the Filipino community. They have presented that the perceived benefits of tobacco control outweigh the negative effects on government revenue, if any.
Policy actors 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 – were effectively used as arguments to support the policy,
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.
Anti-tobacco groups, policy champions, and the Department of Health used various media and strategies to communicate the issue and the policy solution to the public. Health professionals through their professional associations stood as patient advocates and joined anti-tobacco groups in advocating for demand reduction tobacco control strategies. For example, most of the members of the New Vois Association Philippines attribute the loss of their vocal cords and/or cancer to excessive tobacco use. Some of these members presented themselves as the “living testimony” on the effects of smoking to help raise the awareness of the public, especially the youth and the poor.