# Presentation: 079883

## The International Tobacco Control 

**The International Tobacco Control **
**Policy Evaluation Project: Evaluating and Understanding the Impact of Policies of the Framework Convention on Tobacco Control**
- Geoffrey T. Fong, Ph.D.
- University of Waterloo

*141st Meeting of the U.S. National Cancer Advisory Board, Bethesda, MD*
*February 6, 2007*

## “Tobacco is the most effective agent of death ever developed and deployed on a worldwide scale.”
					– John Seffrin, President,
                             	 	  ACS and UICC (2002)

*“**Tobacco is the most effective agent of death ever developed and deployed on a worldwide scale.”*
*	**	**	**	**	**– *John Seffrin, President,
-                              	 	  ACS and UICC (2002)

*“**Tobacco use is unlike other threats to global health. Infectious diseases do not employ multinational public relations firms. There are no front groups to promote the spread of cholera. Mosquitoes have no lobbyists.”*
- 			– WHO Zeltner Report (2000)

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## Facing the Challenge

**Facing the Challenge**

**What must we do to flatten the curve? **
**Population-level interventions such as FCTC policies**

## Demand Reduction Provisions of the FCTC

- Packaging and labelling (Article 11)
- Warnings
- Elimination of misleading descriptors (e.g., “light” “mild”)
- Advertising, promotion, and sponsorship (Article 13)
- Protection from exposure to tobacco smoke      (Article 8)

**Demand Reduction Provisions of the FCTC**

- Price and tax measures to reduce demand (Article 6)
- Dependence and cessation (Article 14)
- Education, communication, training, public awareness (Article 12)

## Potential of Policies to Flatten the Curve

**Potential of Policies to Flatten the Curve**

**Impact of policies depends on factors including:**
**– ****Intervention date**
**– ****Effect size**

## Article 11—Warnings and messages

**Article 11—Warnings and messages**

**should be 50% or more** of the principal display areas but **shall be no less than 30%...**
**may be** in the form of or include pictures or pictograms
**shall contain information on relevant constituents and emissions**

**Does size matter? Are graphic images effective? **

***“******Each Party shall, within a period of three years after entry into force of this Convention for that Party, adopt and implement, in accordance with its national law, effective measures...”***

**What does “effective” mean?**

## Opportunities Afforded by the FCTC

**Opportunities Afforded by the FCTC**

**Opportunity for science:**
- 	– Time-limited opportunity to study population-based interventions: (1) measure the impact of policies and (2) identify the causal mechanisms for policy impact
**Opportunity for evidence-based policy: **
- 	– Create the evidence base to inform the creation of _effective_ tobacco control policies
- 	– Determine the relative strength of FCTC policies
- 	– Counteract disinformation and misinformation from the tobacco industry

## Challenges to Evaluating Policies

**Challenges to Evaluating Policies**

- Not possible to conduct randomized controlled trials (RCTs) on policies
- But it _is_ possible to evaluate the impact of policies using natural experiments (“quasi-experiments”)
- 	1. Multiple country comparisons: _international_ studies
- 	2. Common methods and measures across countries
- 	3. Cohort studies: focus on impact on _individuals_

## The International Tobacco Control Policy Evaluation Project

**The International Tobacco Control Policy Evaluation Project**

## The ITC Surveys

**The ITC Surveys**

**Notes:**
Extensive surveys of representative samples of adult smokers in each country
First-ever international cohort survey of smoking
First-ever research project evaluating tobacco control policies internationally
ITC surveys now in countries with over half of the world’s population
Building capacity throughout the world for tobacco control research and building collaborations among countries

## Goal 1: Rigorous evaluation of national-level tobacco control policies of the FCTC:
Goal 2: To understand how and why these policies work (if they work)

**Goal 1: Rigorous evaluation of national-level tobacco control policies of the FCTC**:
**Goal 2: To understand **_**how**_** and **_**why**_** these policies work (if they work)**

**?**

**Policy**

**Behavior**

- What’s inside the black box?

**Research Goals of the ITC Project**

**Goal 3: Disseminate findings to policymakers**
**	****  – ****Build evidence base for FCTC**
**	****  – ****Promote evidence-based policies**

## Warning Labels: Article 11 of the FCTC

**Warning Labels: Article 11 of the FCTC**
**Evidence from the ITC Project**

**Notes:**
the ITC Project has provided research findings relevant to all of the policy domains of the FCTC, but I would just like to go over findings in one domain—warning labels.
As mentioned earlier, warning labels represents an important policy domain. Warning labels are designed to inform the public about the harms of smoking.

## Warning Labels in the U.S. vs. Canada

**Warning Labels in the U.S. vs. Canada**

**– ****Since 1984**
**– ****4 messages**
**– ****Side of pack**

**– ****Since 2001**
**– ****16 messages**
**– ****50% of front and back**
**– ****New set coming in 2008**

## Examples of Graphic Warnings

**Examples of Graphic Warnings**

## Visual Impact of the Canadian Warning Labels

**United States**

**Canada**

**Visual Impact of the Canadian Warning Labels**

**Notes:**
Distri

## October 2002

**October 2002**

**May 2003**

**U.K.**

**Notes:**
What happens when a country changes warning labels? We examined this in the ITC Four Country Survey. The UK (as did the entire EU) changed its warning labels up to the FCTC minimal standard.

## Enhancing warning labels increases label salience/noticing

**The enhancement of warning labels in the U.K. had a huge impact on labels salience/noticing. But this is a measure of noticing, where mere novelty alone would be expected to have a huge effect**

**Enhancing warning labels increases ****label salience/noticing**

**Results from Hammond et al. *****Am J Prev Med***** (2007)**
**Released today**

## Thinking about the health risks of smoking

**Thinking about the health risks of smoking**

**Still a significant increase in U.K. compared to the other countries, but **_**not**_** above Canada. Evidence for limitation of effect of mere text/size enhancements relative to graphic elements.**

**Hammond et al. *****Am J Prev Med***** (2007)**

## Do warning labels increase knowledge?

**Do warning labels increase knowledge?**

**Only Canada had a warning label about impotence at Wave 1, but then U.K. added an impotence label between Wave 1 and Wave 2**

## Do warning labels increase knowledge?

**Do warning labels increase knowledge?**

**Substantial increase in knowledge about impotence in the U.K. compared to the other three countries after the label on impotence was introduced in the U.K.**
**In U.K.: 14% more smokers = About 1.5M smokers**
**In U.S.: 14% more smokers = About 7M smokers**

## Implications for FCTC Implementation 

**Implications for FCTC Implementation**** **

**Minimal Standard vs. Recommendations:**
**should be 50% or more** of the principal display areas but **shall be no less than 30%...**
**may be** in the form of or include pictures or pictograms

**should be**

**Results from the ITC Project suggest that countries who implement the FCTC label policy at its highest level will experience greater impact, compared to the minimal standard**

## Warning Labels of Malaysia, Thailand, China

**Warning Labels of Malaysia, Thailand, China**

**Notes:**
As you can see, the Thai warnings are larger, clearly distinguished from the design of the brand. The Malaysia warnings are very general: Smoking may be hazardous to health. It is like the U.S. labels--on the side of the pack and it has been this way since 1977.

But now, the Malaysian government is considering enhancing the labels so that they are much larger, on the front and back of the pack, and contain graphic images, like the new Thai warnings.

## Relationship Between Labels and Quitting

**Relationship Between Labels and Quitting**

- Labels Make You Think About Risks

- Quit Attempt

- Controlling for Gender, Age, Income, Education, Ethnicity, Prior Quit Attempts, Intentions to Quit

- Smokers who report that the labels make them more likely
- to think about risks of smoking were:
-    — more likely to **attempt to quit**     (OR = 1.14)*
-    — more likely to **successfully quit** (OR = 1.89)*
- * Statistically significant at p < .05

- Successful quit attempt

**Notes:**
Important result because a label-specific variable is linked to important public health outcome. Thus Label policy-->quitting

## Population-level interventions are needed to fight the growing tobacco epidemic. 
FCTC: opportunity for research and for using research to inform policy
NCI-supported research is making a difference throughout the world and is creating evidence base for future U.S. efforts

- Population-level interventions are needed to fight the growing tobacco epidemic.
- FCTC: opportunity for research and for using research to inform policy
- NCI-supported research is making a difference throughout the world and is creating evidence base for future U.S. efforts

**Concluding Thoughts**

## International Tobacco Control Policy Evaluation Projecthttp: / / www.itcproject.org http: / / www.roswelltturc.org

**International Tobacco Control Policy Evaluation Project****http:**** ****/**** ****/**** ****www.itcproject.org**** http:**** ****/**** ****/**** ****www.roswelltturc.org**

**    ****ITC Project Research Support**

- Core support provided by the U.S. National Cancer Institute to the Roswell Park TTURC (P50 CA111236)

- Additional major funding provided by the Canadian Institutes of Health Research

## ITC Survey Research Team

**ITC Survey Research Team**

**  ****Canada**
-    Geoffrey T. Fong
-    Mary E. Thompson
-    Christian Boudreau
-    K. Stephen Brown
-    Sharon Campbell
-    David Hammond
-    Paul W. McDonald
-    Changbao Wu
-    Mark P. Zanna

**  ****United States**
-    K. Michael Cummings
-    Gary A. Giovino
-    Andrew Hyland
-    Richard J. O’Connor
-    Frank J. Chaloupka
-    Fritz L. Laux
-    Hana Ross
-    Maansi Travers

**  ****Australia**
-    Ron Borland
-    Mohammad Siahpush
-    Melanie Wakefield
-    Hua Yong
-    David Young

**  ****United Kingdom**
-    Gerard Hastings
-    Ann McNeill
-    Louise Hassan
-    Anne Marie Mackintosh
-    Fiona Harris

**  ****Thailand**
-    Buppha Sirirassamee
-    Warangkana Polprasert
-    Philip Guest
-    Steve Hamann
-    Prakit Vateesatogkit

**  ****Malaysia**
-    Maizurah Omar
-    Foong Kin
-    Rahmat Awang

**  ****Bangladesh***
-    Nigar Nargis

**  ****Korea**
-    Hong Gwan Seo
-    Yoo-Seock Cheong
-    Seung-Kwon Myung
-    Wonkyong (Beth) Lee

**  ****China**
-    Jiang Yuan
-    Yang Yan
-    Feng Guoze

**  ****Mexico**
-    James Thrasher

**  ****Uruguay**
-    Marcelo Boado
-    Eduardo Bianco

**  ****India***
-    Prakash Gupta
-    Dhirendra Sinha
-    Prabhat Jha

**  ****France**
-    Sylviane Ratte
-    Pierre Arwidson
-    François Beck

**  ****New Zealand**
-    Nick Wilson
-    George Thomson

***** ITC Surveys currently in development

**  ****Sudan***
-    Asma Elsony

**  ****Netherlands***
-    Marc Willemsen

**  ****Russia***
-    Marine Gambaryan