Thoughts on the lowering of MACR

I cannot seem to understand why there is “clamor” among policy makers to decrease MACR in the Philippines when the global trend is to increase it. I stand with the position of professional and civic groups opposing the proposed measure. First, we need to consider evidence that children below 15 or 12 years old may know what is right or wrong but most of the time fail to internalize the consequences of their actions. Rather than putting them behind bars, we should focus on addressing this problem. The government can establish institutions that can assist our children, their families and communities in educating them about responsible citizenship. Or maybe existing institutions can do a better job in bridging the gap. Second, the most common reasons for children being in conflict with the law can be traced back to poor education and poverty. Perhaps, alleviating these children and their families from poverty will not give the motivation to commit crimes. While this solution is far-fetched, the recognition of the root-cause of societal problems will prevent us from promoting backward policies such as that of lowering the country’s MACR.

Why are our policy makers keen on putting these children behind bars especially when the justice system is juvenile? Juvenile in the sense that it is still struggling to cope with the current number of children in conflict with the law. Therefore, it is unjust to subject these children to criminal trials and/or shelter them under dilapidated facilities under a system that clearly doesn’t put these children’s welfare on top of its priorities. Why are we putting much focus on CICL when they account for only 2% of registered crimes? Shouldn’t the focus shift on bigger crime groups intimidating children to do their dirty jobs? What’s happening, clearly, is like the current war on drugs. This government is scratching the surface, targeting the most vulnerable instead of capturing the mastermind.

The Global Burden of Disease and Some Implications to Health Policy in the Philippines

The Global Burden of Diseases Study (GBD) is a collaborative project of about 500 researchers in 50 countries led by the University of Washington Institute for Health Metrics and Evaluation (IHME). It is the world’s largest systematic, scientific inquiry that quantifies the levels and trends of health loss by determining the prevalence, morbidity and mortality for hundreds of diseases, injuries, and risk factors that are of global significance. The results of the GBD show how socioeconomic development has generated many health achievements but also emerging challenges in both national and global contexts. Over the years, it has been extensively used to inform evidence-based policy and health systems design.

 

In the Philippines, the observed Filipino life expectancies increased by almost 2 years: females 73.1 (versus 71.4 in 1990), males 66.6 (versus 64.6 in 1990). We also saw a significant decline in the trend of child mortality between 1990 and 2017 (Under-5: 56.0, 26.6; Under-1: 36.0, 19.9). These numbers provide us a snapshot of how our current policies positively impact the health of the Filipino people.

 

As with many other low- and middle-income countries, the Philippines is still facing a double burden of disease. While the country continues to battle with the problem of infectious diseases, it is also experiencing a rapid increase in chronic NCDs at the same time. This double burden of disease places a great toll on the health system and the economy. Non-communicable diseases (NCDs) and lifestyle-related diseases like ischemic heart disease and stroke have remained in the top primary causes of death. In fact, six of the ten leading causes of death are non-communicable diseases (ischemic heart disease, stroke, chronic kidney diseases, diabetes, hypertensive heart disease and COPD). Lower respiratory tract infection and tuberculosis remain as the third and fifth leading causes of death, respectively.

 

Disability burden on Filipinos such as low back pain, headache disorders, diabetes, mental health problems, vision and hearing loss, and other chronic diseases, has significantly risen. The Philippines’ greatest risk factors driving the most death and disability come from a combination of metabolic (high fasting plasma glucose, high blood pressure, high BMI, high LDL, impaired kidney function), environmental (air pollution), and behavioral risks (dietary risks, malnutrition, tobacco, alcohol use).

 

According to the Financing Global Health Database (2017), the Philippine government spent $98 on health per person in 2015. Majority of health care spending came from out-of-pocket payments which was estimated to be $178 per person in 2015. The same database projected that in 2040, even when the government increases its health expenditure, the bulk of health care spending in the Philippines will still come from out-of-pocket payments. The expected OOP spending will rise to a staggering $590 per person or more than P30,000 in today’s exchange rate (US$1 = PhP52.15).

In summary, the study found that although people are living longer, we are spending more time and money in illness. These findings inform decision-making by providing policy makers with accurate, up-to-date information to identify vulnerable populations, conduct disease surveillance, and evaluate the efficacy and cost-effectiveness of current health interventions.

 

These findings also indicate that health issues can vary from country to country. Perhaps, we can expect that the same is true at the local level. Health issues will vary within the country especially when examined through our geopolitical divisions. People in the urban areas have greater access to health care services compared to those living in rural areas. However, urban areas also concentrate new risks and hazards for health. As such, the Philippines should address not only inequities in health care but also emerging threats brought about by rapid urbanization and globalization.

 

Data and information from GBD can assist the government in understanding the drivers/promoters of the observed trends. The government can effectively use data from the GBD to examine emerging challenges and explore opportunities for action. Future policies should extend across multiple sectors to include environment, urban planning, social insurance, education, and even transportation. There is a growing trend that emphasizes the need to strengthen (and maybe improve) current health interventions on infectious diseases. However, the country’s health system should now shift its focus from a highly curative system to one that is preventive and health promotive. Or maybe, at least be prepared in reducing health risks and hazards that are highly modifiable or preventable.

 

Ultimately, the GBD proved that development drives, but does not necessarily determine, the health status of the people. We must keep in mind, therefore, that health conditions exist in the same continuum which reflect underlying social conditions such as poverty and inequity. Given the nature of health conditions, the growing burden of disease reinforces the need for an integrated, multi-sectoral approach at the national and subnational levels that address health system functions (health promotion & prevention, cure, and rehabilitation) rather than disease categories by instituting cost-effective interventions that improve health beyond the health system.

POLICY ANALYSIS REPORT: Graphic Health Warnings Law (Part 4)

POLICY EVALUATION

Evidence is one factor that influence policy-making and this can be generated through research. Research is a scientific process designed to produce new knowledge to improve the understanding of the world or to explain a phenomenon. It has substantially contributed to this policy in many ways at various stages of the policy cycle. The succeeding sections present the role of research in these stages.

Issue Recognition and Policy Identification

Research, in the early stages of the policy cycle, helped define the nature and severity of the problem. It helped issues get into the government’s policy agenda. Research evidence were effectively utilized by several policy actors such as the WHO, DOH, and anti-tobacco groups.

Health statistics from the DOH provided policy actors and the public with the information about the health effects of tobacco use, specifically tobacco-related diseases. This information supported the argument for the enactment of better, stricter tobacco control policies that will lessen the burden of these diseases.

National and global surveys such as the Global Adult Tobacco Survey (GATS) and the Global Youth Tobacco Survey (GYTS) helped monitor tobacco use among Filipino adults and the youth. These surveys provided essential information regarding the tobacco epidemic. These surveys covered essential indicators such as (1) knowledge and attitudes towards cigarette smoking, (2) prevalence of cigarette smoking, (3) role of media and advertising in the use of cigarettes, (4) access to cigarettes, (5) environmental tobacco smoke, and (6) cessation of cigarette smoking. Information from these surveys stimulated the development of tobacco control policies and programs in the country.

Global and local surveys proving the ineffectiveness of text-only health warnings on cigarettes products to change smoking behavior prompted policy actors to review existing policy options. As such, studies proving the effectiveness of large graphic health warnings in changing smoking behavior and deterring non-smokers from taking up the habit were used as justifications for the enactment of a policy similar to the recommendations of the WHO.

Policy Formulation

Research has also played a significant role in the formulation of the policy. The WHO FCTC, a set of tobacco control guidelines established from systematic review of research evidence, contributed to the introduction of strong health warnings and the adoption of graphic health warnings in the country.

In the Philippines, a concept test on cigarette packaging designs was conducted by FCAP in 2007 through a quantitative Concept Acceptance Test. The nationwide study provided a background on the public’s perception about smoking and its health effects. Likewise, the study provided feedback on various graphic health warning mock-ups that helped anti-tobacco advocates choose which were the most effective for the Philippine market.

Policy Implementation

Currently, no study has explored the impact and effect of the graphic health warnings on smoking behaviors of Filipino smokers nationwide. A small study, however, that explored how graphic health warnings had affected smoking behavior of Quezon City residents was conducted by UP Diliman Communication Research students in 2016.

The researchers surveyed 402 Quezon City smokers and conducted two focus group discussions from October to November 2016. The results of the study suggest that thinking about the dangers of smoking and correct knowledge of smoking-related diseases are the strongest factors correlated with the intention to quit or change smoking behavior which is in congruence with the overall goal of the GHW law (Aseo et al., 2016).

The study also presented aspects of the implementation where the policy is problematic. First, the fact that buying cigarette on a per-stick basis is prevalent in the Philippines greatly reduces the probability of smokers being informed of the dangers of tobacco use. And second, most smokers do not rely on tobacco packages for health information. Majority of smokers actually rely on other media (i.e. television) for information on smoking.

What’s Next?

While current evidence suggests that graphic health warnings are effective in informing smokers of the health effects of tobacco consumption, future research will be helpful in evaluating the effectiveness of graphic health warnings in changing consumer behavior (i.e. decreasing tobacco consumption, deterring non-smokers from initiating smoking). Findings from future studies will eventually determine the fate of the policy – whether to improve or repeal the policy.

 

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Calonzo, A. & Arcangel, X. (2014). Senate, House OK graphic health warnings on cigarette packs. GMA NEWS ONLINE. Retrieved from http://www.gmanetwork.com/news/news/nation/364872/senate-house-ok-graphic-health-warnings-on-cigarette-packs/story/

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Crisostomo, S. (11 February 2016). Tobacco panel issues rules for graphic health warning law. The Philippine Star. Retrieved from https://www.philstar.com/headlines/2016/02/11/1552156/tobacco-panel-issues-rules-graphic-health-warning-law

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Garcia, L. (5 March 2016). GHW is now in effect. Business Mirror. Retrieved from https://businessmirror.com.ph/ghw-law-is-now-in-effect/

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POLICY ANALYSIS REPORT: Graphic Health Warnings Law (Part 3)

POLICY IMPLEMENTATION

Principal-Agent Approach

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.

POLICY ANALYSIS REPORT: Graphic Health Warnings Law (Part 2)

POLICY FORMULATION

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.

Policy Context

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.

Situational Factors

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).

Cultural Factors

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.

Structural Factors

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.

 

Policy Content

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.

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.