Compliance with Health Warning Requirements on Cigarette Packs:
A Nine-Country Study
Joanna Cohen, PhD, Jennifer Brown, MPH, Carmen Washington, MPH, Jacqueline Ferguson, MHS, Katherine Clegg Smith, PhD
Background
•
•
Health warning labels (HWLs) on cigarette packs are important for communicating
the risk of using cigarettes
We assessed whether HWLs are being implemented as required by law in nine lowand middle-income countries
Methods
•
•
•
•
•
•
Cigarette packs systematically purchased in nine countries in 2013: Bangladesh,
China, India, Indonesia, Mexico, Pakistan, the Philippines, Thailand and Viet Nam
In each country, bought one of every unique cigarette pack from sample of vendors
in 36 low-, middle- and high-socioeconomic areas across three major cities
Two independent coders assessed packs for compliance with four components of
HWL requirements in force at time packs were purchased: warning location, warning
size, warning text colors, warning text font
To determine compliance with coverage requirements, used cutoff of one
percentage point less than what was required (e.g., if HWL had to cover 30 percent
of front panel, coverage greater than 29 percent was categorized as compliant)
Packs had to meet coverage requirements for both front and back panels (where
appropriate) to be considered coverage compliant
Descriptive statistics conducted using Stata 13
Results
Bangladesh
•
•
•
Compliance with all four key HWL requirements was high for packs from all
countries except for India where 47 percent of the packs were compliant and the
Philippines where 17 percent of packs were compliant
In most instances of non-compliance, warnings or warning text were found to be
smaller than specified by country requirements
Continual surveillance of tobacco packaging can inform advocacy efforts to
strengthen implementation of packaging and labeling laws
Since data collection, Viet Nam, Thailand and Indonesia have implemented new
HWLs; India, Bangladesh, Brazil, Pakistan and the Philippines have passed new
HWL regulations
93%
100%
India
100%
100%
100%
100%
Front and
back of
pack
Black text
on white
background
Front and
back of
pack
Text and
background
color contrast
Front of
pack
Red & white
text on black
background
54%
96%
96%
80%
52%
30% of both
sides
99.7%
18 pt. font
40% of front
0.75 to 1
ratio, vertical
to horizontal
Indonesia
4mm tall
text
30% of both
sides
Mexico
Pakistan
100%
90%
100%
100%
100%
84%
“Part of pack
that is easily
read”
Black text on
white
background
Front and
back of
pack
Yellow and
black; black
background
Front and
back of
pack
Black text
on white
background
N/A
90%
96%
99%
97%
100%
No health
warning size
requirement
3mm tall
text
30% of front
and 100% of
back
Ranges from
9-11 pt.
40% of
both sides
2mm tall
text
Discussion
•
China
Thailand
Thailand
Philippines
Thailand
Viet Nam
Viet
Nam
100%
98%
100%
97%
100%
100%
Front of
pack
Black text
on white
background
Front and
back of
pack
Content as
issued by
MOH
Front and
back of
pack
Black text
on white
background
68%
32%
100%
76%
100%
30% of front
Text must
comprise
50% of label
92%
55% of both
sides
30% of both
sides
2mm tall
text
Acknowledgements: This work was supported by a grant from the Bloomberg Initiative to Reduce Tobacco Use to the Johns Hopkins Bloomberg School of Public Health; Conflicts of Interest : None
www.globaltobaccocontrol.org/tpackss
Size as
issued by
MOH