The policy uses the principal-agent approach of implementation where the government has mandated its various agencies to implement the law in various capacities. Other than the DOH, 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to ensure that cigarette stamps are not affixed on noncompliant packages and to certify under oath that the products withdrawn are compliant with R.A. No. 10643. The Inter-Agency Committee on Tobacco (IAC-T), created under R.A. No 9211, monitors overall compliance with the law, and institutes the appropriate action for any violation of the law. 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.
Factors Affecting Implementation
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 addresses the issue on information asymmetry; however, it lacks the ability to fully change several mental models (i.e. smoking is cool & masculine) and other unique factors imbedded in the Filipino culture that could drive or deter the implementation of the policy.
Tobacco Industry Interference
While there seems to be a strong political will from the DOH leadership to sustain the measure, there is certainly room for some resistance to change. Many stakeholders have identified the PTI as a stakeholder that actively opposes GHW as a tobacco control policy. While this opposition was made apparent by PTI in the past, it eventually expressed moderate opposition to this policy during the policy formulation phase when it realized that the enactment of the policy was inevitable.
As the sole group of opponents with the intention to protect their commercial interests, tobacco companies effectively used their power to challenge, discredit, and obstruct the implementation of effective tobacco control measures such as the GHW Law. Due to their overwhelming resources and ability to effectively mobilize these, PTI has the capacity to hire the best law firms for their legal defense pitted against underpaid government lawyers with a ton of caseloads.
Research conducted by anti-tobacco groups showed that these actions included (1) demanding a seat at government negotiating table, (2) drafting and distributing sample legislation that is favorable to the tobacco industry, (3) attempting to bribe legislators, (4) financing government initiatives to gain favor, (5) using tobacco farmers as ‘front groups’, (6) and defending commercial profit (HealthJustice Philippines, 2014).
The PTI has a long history of opposing tobacco control measures. In 2014, PTI successfully reduced the size of originally proposed graphic health warning labels on cigarette packs and convinced legislators to place them on the lower portion of the front and back panels which is opposite the recommendation of the WHO (SEATCA, 2018).
The tobacco industry’s powerful influence on the policy process also became apparent during the policy’s implementation. Despite proven capacity to produce cigarette products with graphic health warnings, Philippine tobacco companies delayed the implementation of the law citing administrative feasibility, logistical nightmare, and costly exercise among their reasons. For transnational companies, this was a case of double standards.
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.
Most stakeholders also do not agree with PTI being included in the Inter-Agency Committee-Tobacco (IAC-T). Most stakeholders believe that PTI could meddle with decision about cigarette policies of the government by sitting in a government tobacco regulatory body that seeks to regulate their industry. Many of these stakeholders have called on the government to remove the PTI from the IACT.
There is no doubt that the passage of the GHW law greatly benefited from strong political support, leadership from DOH, and advocacy-driven action by anti-tobacco groups. The country’s experience may not be comparable with the experiences of other countries that have implemented similar reforms. The tobacco industry’s power remains a significant influence in the tobacco control policy process of the Philippines. However, the experiences with the GHW policy process in the country has established a strong foundation for future reforms, especially in tobacco control.
Health information source
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. Graphic health warnings are intended to prompt the smokers to think that they could contact diseases depicted in the pictures. Worldwide, GHWs were proven effective in prompting smokers to think about the dangers of smoking which is associated with increased intention to quit.
It is assumed that (1) the more smokers think about the dangers of tobacco use, the more likely they are to consider quitting; (2) and exposure to the dangers of smoking will prevent non-smokers and the youth from initiating tobacco use. This is where the graphic health warnings should supposedly show their impact.
In the case of the Philippines, this is not entirely true. Graphic health warnings lag behind other media as a primary source of information about smoking. It was found that smokers prefer television as primary source for smoking information. Not much has changed since 2008 when the study by FCAP found that 77% of smokers saw warnings on television while only 19% saw them on cigarette packaging.
A more recent study showed that 73% of smokers relied on television to learn about tobacco-related diseases (Aseo et al., 2016). Graphic health warnings only ranked as the second most cited source of information about the health effects of tobacco use. The same study found that majority of smokers had seen the graphic health warnings on cigarette packages. Some of the respondents said they were disgusted and scared by the graphic health warnings and actually prefer throwing the packs away. However, some of them did not pay attention to the graphics and simply threw the cigarette packs.
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 media other than the graphic health warnings printed on tobacco packages.
Mode of purchase
The Philippines was once called as a country 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 per-stick buying in the country has greatly affected the implementation of graphic health warnings on tobacco packages.
Only about 20% buy cigarettes per pack (versus about 80% buying per stick) making it difficult to ascertain the effectiveness of GHW on tobacco packages in changing the tobacco landscape of the country (Aseo et al., 2016). Buying cigarettes per stick as opposed to buying per pack significantly removes the probability of a smoker or potential smoker of seeing these GHWs and thus, defeating the purpose of the policy.
The DOH was concerned about this aspect of the policy’s implementation – cigarettes sold per stick by vendors or retail stores. Hence, in 2016, the Department tapped local government units (LGUs) to help monitor the full implementation of the law at the street or community level. To date, no policy has been issued to regulate the sale of cigarette products per pack at the community level.
In general, the graphic health warnings have been proven to be effective in informing smokers about the dangers of tobacco use. It plays a huge role in changing the behavior of smokers regardless of literacy and economic class. It has been shown that around 42 percent of those who changed their behavior said the graphic health warnings had a big impact on their decision (Aseo et al., 2016). But despite these evidence, graphic health warnings fall short in attaining the maximum benefit it promised due to lapses in the policy’s implementation.