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This chapter contains literature and studies regarding cigarette smoking, cigarette
smokers, and local and international studies about graphical health warnings in cigarette
packages.
Tobacco product is defined as any manufactured product made of leaf tobacco that is
used for smoking, sucking, chewing, or snuffing (WHO FCTC, 2005). There are three types of
tobacco preparation. The first one is the roll of tobacco which is smoked. Cigarette is the best
example of this. The second type is pipe like water pipes. The third is the oral preparation which
is chewed, held in mouth or placed in nose. Examples are snuff, snus, betel and quid (WHO,
2006). Tobacco contains nicotine and many carcinogens. Hence, it is an addictive plant (WHO,
Cigarette smoking has long been viewed as an activity associated with men, at least in the
Philippine context. Recently, however, female smoking caught the interest of health advocates
due to the escalation in smoking incidences. Cigarette smoking is one of the country’s most
potent killers causing several diseases and causing people’s deaths regardless of age and sex.
According to Department of Health (DOH) Secretary Janette P. Loreto- Garin, stated that as
reported, about ten (10) Filipinos die every hour because of smoking (www.ntrc.gov.ph).
Filipinos mainly smoke cigarettes, which include manufactured cigarettes and hand-
Based on the 8th National Nutrition Survey conducted by the Food and Nutrition
Research Institute (FNRI), smoking prevalence in the Philippines has gone down from 31% in
2008 to 25.4% in 2013; or specifically, from 53.2% in 2008 to 44.7% in 2013 in males, and from
exceeded the global average of 36% with smoking prevalence of 44.7% in 2013. The same is
also depicted for female smoking incidence at a higher rate of 7.8% against the global average of
7%. The smoking incidence of the total population was 25.4%, which was higher than the 21%
worldwide average. Nonetheless, in spite of these larger than normal figures, smoking incidence
in the Philippines declined in the five year period (NTRC Tax Research Journal, 2016).
A repository for the collection, analysis, validation and dissemination of all smoking and
health-related data was established by the World Health Organization. The data received from
various member countries were compiled into a book entitled Tobacco or Health: A Global
Status Report, 1997. This report showed smoking prevalence and other tobacco use-related data
from various countries and presented an analysis. It is estimated that there are approximately 1.1
billion smokers worldwide, of which 900 million are men and 200 million are women. The sex
ratio of men to women is 2:1 for developed nations and 7:1 for developing nations. Smoking
prevalence in men and women averages 42% and 24%, respectively, for developed countries,
and 48% and 7%, respectively, for less developed countries (www.ncbi.nlm.nih.gov).
In comparison, twenty-eight percent or 17.3 million Filipino adults age 15 years and
older are current tobacco smokers, according to the results of the 2009 Global Adult Tobacco
Survey (GATS). Almost half (48 percent or 14.6 million) of adult males and 9 percent (2.8
million) of adult females are current smokers. Moreover, 23 % of Filipino adults are daily
tobacco smokers: 38 % for males and 7 % for females. Cigarettes are smoked by 47 % of men
and by 9 % of women. On the average, male daily smokers consume 11 cigarettes per day while
Previous studies showed that knowledge of smoking health threats may vary across the
smokers’ ethnicity as well as educational level. Higher educational levels were related to higher
knowledge on smoking health risks (Ma, Tan, Freely &Thomas, 2002; Ma, Shive, Tan &
Toubbeh, 2002). Smokers with lower level of knowledge about the health dangers of smoking is
associated with their positive attitudes toward smoking (Shankar, Gutierrez, Mohamed, &
It was said that beliefs became part of a person’s system and these beliefs influenced the
person’s choices and behaviors. Occasional smokers do not smoke daily, or if they smoke they
smoke just a few. A study (Hammond, 2008) showed that most smokers perceive themselves
Attitudes toward smoking are significantly associated with smoking status (Shankar,
Gutierre-Mohamed &Alberg, 2000; Marin, Marin, Perez, Stable ,Otero, Sabogal & Sabogal,
1990; Klesges, Somes, Pascale, Klesges, Murphy & Williams, 1988). Particularly current
smokers perceived smoking as having positive attributes while the non-smokers perceived
smoking as having negative characteristics (Taylor, Ross, Goldsmith, Zanna &Lock, 1998;
related diseases were lesser than the nonsmokers and former smokers even though the perceived
seriousness of all the groups was almost the same(Klesges, Somes, Pascale, Klesges, Murphy &
Non-smokers as well as those who quitted smoking had more negative perceptions
regarding smoking compared to smokers. Attitudes toward smoking are associated with socio-
demographics, educational levels, and ethnicity. Younger and more educated smokers perceived
smoking with higher personal risks of heart disease or cancers (Shankar, Gutierrez, Mohamed &
Women and men have different psychological patterns that influence their behavior. The
same is evident in their motivation to smoke cigarette. Men are found to smoke when they are
experiencing positive emotions while women smoke to contradict any negative feelings they
harbor. Men are also more prone to smoke in public places with their peers, whereas women,
smoke in hidden places. Women are known to smoke to control weight and to relieve stress,
which may come from different pressing factors such as given related causes: strained family
relationships, peer pressure, poor religious background, etc. Men too, start smoking with similar
reasons in lesser frequencies. However, men tend to be more dependent on nicotine compared to
women, which is most likely the primary influencing factor on cigarette addiction for men. In
addition, men use cigarette as a social tool. Todd, et. al (1996) cited by NTRC Tax Research
Journal (2016), have concluded that role socialization and smoking have a complex relationship
where there are cases that socialization is used as means to get rid of stress.
Once thought to be relatively harmless and pushed as a 'past time' of sorts even by the
medical community, scientific studies have proved beyond a doubt that tobacco use – and
Cigarettes are considered to be among the most deadly and addictive products made by
men. If the users will smoke cigarettes according to the intention of the cigarettes manufacturers,
cigarette smoking can kill half of its users (WHO, 2006 cited by Aguillon, J.M & Romano, P.B).
Scientific evidences show that the consumption and exposure to tobacco smoke cause
these three: (1) Death, (2) Disease, and (3) Disability. Aside from this, it has been found out that
there is a time interval between the exposure to smoking and the start of tobacco-related diseases
As part of the Global Burden of Disease Study carried out by the Harvard University
School of Public Health in 1997, it was projected that mortality and morbidity from tobacco use
will increase by almost threefold worldwide in 20 to 25 years. Similar predictions have been
made by the Oxford University Center headed by Sir Richard Doll, who was one of the first
researchers to link cigarette smoking with lung cancer in the 1950s. Cancer, cardiovascular
diseases and chronic obstructive pulmonary disease continue to be the main health problems
According to the Tobacco Atlas, the Philippines experienced 71, 850 tobacco-induced
deaths in 2010, which comprised 19.6% of deaths of men and 9.4% of deaths of women.
Congruent with smoking prevalence rates, more deaths occur in both men and women in the
Philippines compared with other middle income countries (NTRC Tax Research Journal, 2016).
Due to biological differences, some men and women smokers suffer distinct illnesses.
Risks in developing cervical cancer, breast cancer, ulcer and menstrual and pregnancy
complications are higher for female smokers than non-smokers. Men, on the other hand,
reportedly suffer from a decrease in sexual potency (NTRC Tax Research Journal, 2016). Other
than these, both men and women smokers are also at risks of the four main diseases generally
cardiovascular diseases (including heart disease and stroke); (2) diabetes; (3) cancers; and (4)
chronic respiratory diseases, including chronic obstructive pulmonary disease (COPD) and
asthma. These four NCDs are caused, to a large extent, by four modifiable behavioral risk
factors: tobacco use, unhealthy diet, physical inactivity, and harmful use of alcohol (Department
of Health, 2011).
responsible for more than two-thirds of lung cancer, vesicle, esophagus, larynx, mouth and throat
(WHO, 2006 cited by Aguillon, J.M & Romano, P.B); 40% of chronic respiratory diseases,
emphysema and bronchitis (WHO, 2006 cited by Aguillon, J.M & Romano, P.B); and 10% of
cardiovascular diseases, stroke, heart attacks and other cardiovascular diseases (WHO, 2006
cited by Aguillon, J.M & Romano, P.B). An estimated six million people die from tobacco use
each year, causing nearly 10% of all deaths worldwide, two million more than AIDS, malaria,
Five out of ten leading causes of morbidity in the Philippines in 2009 and 2010 were
tobacco- attributable diseases, namely: Acute respiratory infection (1st), Acute Lower
Respiratory Tract Infection and Pneumonia (2nd), Bronchitis/Bronchiolitis (3rd in 2009 and 6th
in 2010) Hypertension (4th) and Respiratory Tuberculosis (8th). Smoking kills up to half of all
lifetime users. It is an epidemic that kills ten Filipinos every hour. Tobacco use was responsible
for over 58 thousands deaths or nearly 12% of all deaths in the Philippines in 2004, according to
the World Health Organization (WHO) calculations. Almost 80% of these deaths caused by
tobacco were among men. An estimated 6-8% of all deaths in the country are attributable to the
four tobacco-related diseases causing between 23,000-35,000 tobacco-related deaths per year
Tobacco-related diseases have been widely reviewed. According to WHO (2006) cited by
It is now also known that tobacco use contributes to cataracts, pneumonia, acute myeloid
leukemia, abdominal aortic aneurysm, stomach cancer, pancreatic cancer, cervical cancer, kidney
cancer, periodontitis and other diseases. Tobacco seriously damages the reproductive system too,
contributing to miscarriage, premature delivery, low birth weight, sudden infant death and
pediatric diseases, such as attention hyperactivity deficit disorders. Babies born to women who
smoke are, on average, 200 grams lighter than babies born to comparable mothers who do not
smoke.
On the other hand, it’s not only the tobacco consumers who are susceptible to its negative
effects. The second-hand tobacco smoke which is also known as passive smoking has exposed
millions of people including half of the world’s children to the negative effects of tobacco
sudden infant death syndrome in children. The above mentioned diseases are but a few of
second-hand smoking’s harmful effects (WHO, 2006 cited by Aguillon, J.M & Romano, P.B).
The tobacco epidemic is rising rapidly hence the regulation of tobacco products is
critical. All tobacco products can cause disease and death aside from the fact that they are
harmful and addictive (WHO, 2006 cited by Aguillon, J.M & Romano, P.B)
Graphic health warnings that depict the possible consequences of smoking are an
increasingly common feature of tobacco product packaging worldwide. Canada was the first
country to introduce graphic health warnings, replacing text-only health warnings in 2000, with
Venezuela, Panama, Australia, Uruguay, Chile, Belgium, Hong Kong, Korea and New Zealand
had also introduced graphic health warnings, with many others considering or planning to do so
in the future (Elliot & Shanahan Research, 2008). Philippines have also implemented the graphic
health warnings and was approved on July 15, 2014 and took effect on August 7, 2014 (Official
This global phenomenon has been driven, to a large extent, by research that demonstrates
the effectiveness of graphic health warnings in increasing knowledge and awareness of the health
risks of smoking and in encouraging smoking cessation (Elliot & Shanahan Research, 2008).
Much of the research in the area is from Canada, where graphic health warnings appear to
have played a significant role in enhancing both smokers’ and non-smokers’ understanding of
the specific health consequences of smoking, motivating smokers to quit, discouraging relapse,
and deterring potential smokers from starting to smoke (Hammond et al, 2003; Hammond et al,
2004b cited by Elliot & Shanahan Research, 2008). The International Tobacco Control (ITC)
Project examines and compares the effect of various forms of packaging on smoker behaviours
and attitudes across a number of countries and demonstrates the greater effect of the graphic
health warnings compared to text-only warnings (Hammond et al, 2007 cited by Elliot &
Shanahan, 2008). Preliminary studies in Brazil, Singapore and Thailand indicate that graphic
health warnings have also had a positive impact on knowledge of smoking risks, and motivation
to quit (Datafolha Institute, 2002 cited by Elliot & Shanahan Research, 2008).
In essence, recent research continues to highlight the influence of a number of key factors
on the overall effectiveness of graphic health warnings on tobacco product packaging. The
clarity, credibility and reinforcement are emphasised throughout the literature. Significantly, past
research indicates that these factors must accommodate the varying ways in which specific
consumer groups respond to health warnings. Health warning relevance and variety are therefore
also notable. Finally, the introduction of plain packaging has also been raised in the literature as
a future measure that is likely to lend significant support to the impact of health warnings (Elliot
All tobacco products are dangerous and addictive. Government effort should be made to
discourage the use of tobacco in any forms as well as to raise awareness about its harmful and
deadly effects. (WHO, 2006 cited by Aguillon, J.M & Romano, P.B). One government
Republic Act No. 10643 (RA 10643) entitled “AN ACT TO EFFECTIVELY INSTILL
PRODUCTS” was approved on July 15, 2014 and took effect on August 7, 2014, fifteen (15)
days after its complete publication in newspapers of general circulation. (Official Gazette of the
Implementing Rules and Regulations (IRR) of Republic Act 10643 according to the
Purpose
These Rules are adopted to ensure the effective implementation of RA 10643 and
ensuring timely and strict compliance with the templates of the graphic health warnings
and guidelines on the use of such templates, and the ban on misleading descriptors;
provide guidelines to ensure that the graphic health warnings and the ban on misleading
descriptors promote the right to health and information of the people; and provide other
General Provisions
package inserts and onserts, and any outside packaging and labeling, withdrawn
from the manufacturing facilities or imported into the Philippine customs territory
shall bear Graphic Health Warnings on fifty percent (50%) of the lower portion of
the principal display areas or surfaces in accordance with the templates issued by
the DOH.
All cigarette packages and other tobacco product packages shall bear
smoking, on an area of not more than thirty percent (30%) of the display surface
A. Mastercases
bear the textual warning “SMOKING KILLS”. The textual health warning shall
be printed in bold font, in the same single color as the trademark logo, and shall
occupy fifty percent (50%) of each principal display panel, with the purpose that
companies.
B. Inserts
Graphic Health Warnings on inserts shall occupy fifty percent (50%) of
C. Onserts
customary conditions of use; Provided, that the onserts shall be affixed in such a
manner that no part of the Graphic Health Warning printed thereon is obliterated,
obscure or cover, in part or in whole, the Graphic Health Warnings or the location
where the internal revenue strip stamp is to be affixed as may be required by the
BIR.
All outside packaging and labeling shall bear Graphic Health Warnings on
fifty percent (50%) of the principal display areas, in the same quality, color, and
proportion and in accordance with the templates issued by the DOH; Provided,
that for packages that have principal display areas that are disproportionate to the
packaging and labelling, and the DOH shall issue further guidelines accordingly.
E. Reams/Cartons
a. Non-transparent reams/cartons
on fifty percent (50%) of the principal display areas, in the same quality,
color, and proportion and in accordance with the templates issued by the
DOH.
b. Transparent reams/cartons
display surfaces such that all tobacco product package units are visible
from outside, the packages shall be placed inside the ream/carton in such a
c. Partly-transparent reams/cartons
display surface such that some tobacco product package units are visible
from outside, the packages that are visible shall be placed inside the
are prominently displayed and not obscured by any part of the packaging.
the same quality, color, and proportion and in accordance with the
a. The graphic health warnings shall be printed in four colors /-cmyk-/ screen 133 lines
per inch based on a source file of 300 dpi. It shall be printed using current
available technology for purposes of providing vivid and realistic pictures, without the
use of any border, frame or any other design that will effectively lessen the size of the
warning;
b. The Graphic Health Warnings shall be printed or inscribed on the package in a color
which contrasts conspicuously with the background of the package or its labels;
c. The Graphic Health Warnings shall be reproduced in the same quality, color and
proportion as provided by the DOH in the templates or in the digital form, whichever is
d. The text warning accompanying the photographic picture warning shall be worded in
such manner that an ordinary layman will understand what the picture is about and what
the ill-effects of smoking are on the health of the smoker and on the people around him;
e. The text warning shall be placed on areas of the photograph where it will not obscure
Health Warnings and shall appear in clearly legible type and in contrast by typograph,
layout and color, without the use of any border, frame or any other design that will
g. The accompanying text shall be printed in Filipino on the front panel and English on
the back panel. In the case of other containers where there is only one (1) external surface
packaging shall be prominently displayed and the text thereto shall appear in clearly
legible type and in contrast by typograph, layout and color, without the use of border or
frame or any other design that will effectively lessen the size of the additional health
warnings.
Prohibition on Obscurement
cover, in part or in whole, the Graphic Health Warnings or the location where the internal
revenue strip stamp is to be affixed as may be required by the BIR. No part of the
warning may be obliterated, obscured, folded, severed or become unreadable when the
simultaneously and these shall be rotated periodically for each brand family and also for
each brand variant, so that every twenty-four (24) months, the variations of the warnings
shall appear in the market with approximately equal frequency and equal display of
b. Thirty days (30) days after the effectivity of RA 10643, the DOH shall issue a
guidelines with respect to the specific pictures, design, or content of the information
relating to the Graphic Health Warnings, and other information that must appear on the
(NGOs) that have established and proven records of dealing with tobacco-related diseases
and deaths and that have no affiliation with the tobacco industry. All Graphic Health
Warnings issued shall comply with the specifications above and must always present the
d. The initial set of templates is valid for two (2) years from implementation. Within one
(1) year from the effectively of the initial set of templates, the DOH shall issue a new set
of templates, which will take effect upon expiration of the initial set. These new
packages shall bear misleading descriptors or any number or descriptor 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
2015 shall be the reckoning period of the issuance of the initial set of templates for