Effect of the Framework Convention on Tobacco Control and Voluntary Industry Health Warning Labels on Passage of Mandated Cigarette Warning Labels From 1965 to 2012: Transition Probability and Event History Analyses

摘要

Objectives. We quantified the pattern and passage rate of cigarette package health warning labels (HWLs), including the effect of the Framework Convention on Tobacco Control (FCTC) and HWLs voluntarily implemented by tobacco companies. Methods. We used transition probability matrices to describe the pattern of HWL passage and change rate in 4 periods. We used event history analysis to estimate the effect of the FCTC on adoption and to compare that effect between countries with voluntary and mandatory HWLs. Results. The number of HWLs passed during each period accelerated, from a transition rate among countries that changed from 2.42 per year in 1965–1977 to 6.71 in 1977–1984, 8.42 in 1984–2003, and 22.33 in 2003–2012. The FCTC significantly accelerated passage of FCTC-compliant HWLs for countries with initially mandatory policies with a hazard of 1.27 per year (95% confidence interval?=?1.11, 1.45), but only marginally increased the hazard for countries that had an industry voluntary HWL of 1.68 per year (95% confidence interval?=?0.95, 2.97). Conclusions. Passage of HWLs is accelerating, and the FCTC is associated with further acceleration. Industry voluntary HWLs slowed mandated HWLs. The United States implemented the first cigarette package health warning label (HWL) in 1966 with the weak message, “Cigarette smoking may be hazardous to your health” on the side of the pack. By 2012, 209 countries and territories had implemented HWLs, ranging from weak text messages on the side of the pack to strong graphic warning labels (GWLs) on the pack front. 1 Experimental and epidemiological data suggest that HWLs, especially GWLs, are important tools in tobacco control. 2 Indeed, there is some evidence that GWLs enhance relevance and perceived effectiveness of tobacco control messages for individuals in disadvantaged groups 3 and smokers cite GWLs as an impetus for quitting. 4 Fong et al. prepared an extensive review of GWL literature that was published in 2009 concluding that GWLs have been an effective tobacco control intervention in numerous countries worldwide and may reduce disparities in knowledge for tobacco-related harms in countries with low literacy. 5 The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) is a public health treaty designed to address issues of tobacco control. Article 11 of the treaty commits parties to implement large (at least 30% of the front surface area of the pack) rotating labels that may include graphics that may disrupt the impact of brand imagery on packaging and decrease the overall attractiveness of the package. 6,7 By applying transition probability matrices and event history analysis, we quantified the effects of voluntary industry regulation on the underlying process of implementation of HWLs. Understanding how voluntary regulation impedes adoption may help explain why some countries never adopt mandatory HWLs and health policies more generally. Indeed, voluntary regulations have been used to preempt regulation in other health-related areas 8 including food advertising and labeling regulation. 9 This is particularly important in public health as many industries use voluntary regulation to preempt or delay the regulatory process. There has been some research quantifying the effect of the tobacco industry and the FCTC on smoke-free policies. There is some evidence that being connected to GLOBALink (a tobacco control online community) increased the likelihood of ratifying the FCTC. 10 Furthermore, there was a positive effect of the FCTC on strength and presence of tobacco control policies in individual countries. 11 In examining the implementation of HWLs, it is important to consider tobacco companies’ attempts to hamper this process. 1 One way that tobacco companies seek to block or delay tobacco control policies is by implementing ineffective voluntary regulation to displace advertising restrictions 12,13 and smoke-free policies, 14 avoid taxation, 12,15 and delay the FCTC itself. 16 Health warning labels were no different. Between 1992 and 2012, 16 countries made voluntary agreements with the tobacco industry to put weak HWLs on cigarette packages, and in 1992 Philip Morris unilaterally put English-language HWLs on the sides of packages being sold in 49 small, mostly African, countries whose native languages were not English. 1,17 British American Tobacco followed the same practice soon after. To date, no one has quantified the effect of these voluntary HWLs (whether by voluntary agreement or unilateral) on the rate of adoption of stronger HWLs. We describe the process of adopting HWLs over time beginning with the first mandated warning labels in the United States in 1966. We also tested whether the FCTC affected adoption of HWLs and quantified the effect of voluntary industry HWLs on the adoption of strong HWLs.