Study Finds ‘Disturbing’ Health Warnings on Cigarette Packaging Are Effective

Butting Out: The Health Ministry makes no secret of its aim to eventually implement plain packaging for all cigarette brands

Jakarta Globe, Dessy Sagita, Apr 29, 2015

Indonesia requires cigarette warnings cover 40 percent of the packet, far less
than other countries in Southeast Asia. (JG Photo/Yudhi Sukma Wijaya)

Jakarta. Despite the staggeringly high number of active smokers in Indonesia, most people support the use of health warnings on cigarette packaging depicting often disturbing images of tobacco-related diseases and agree the size of the pictures should be increased, a survey has found.

The national survey on the implementation of pictorial health warnings in Indonesia found that 84 percent of respondents agreed the graphic health warnings on cigarette packaging made them concerned about the dangers of smoking.

The survey was carried out by 20 institutions including the Indonesian Tobacco Research Alliance, the Association of Indonesian Public Health Experts’ Tobacco Control Support Center (TCSC) and the International Union Against Tuberculosis and Lung Disease (Union).

The survey, whose results were released on Wednesday, was conducted between March 2014 and March 2015, involving 5,409 respondents in 18 cities.

It also found that 90 percent of people queried, many of them smokers, agreed that the size of the graphic images should be increased to 90 percent of packaging.

Indonesia currently requires all tobacco companies to cover at least 40 percent of the surface of packs with the health warnings.

Thailand and Myanmar require tobacco companies to cover 85 percent and 75 percent of the packs with the health warnings, respectively.

“This is very encouraging; the survey shows that people would really like to see bigger pictures,” Tara Singh Bam, a technical adviser at the International Union Against Tuberculosis and Lung Disease, said on Wednesday. “Even the smokers agree that it would have a bigger impact.”

The survey also questioned cigarette sellers and found that despite concerns that the more stringent regulation would affect their income, nearly 85 percent supported the policy.

“Judging from the people’s positive perspective and the Health Ministry’s commitment, having health warnings that cover 75 percent of the packs by 2017 and plain packaging by 2020 is not impossible,” Singh Bam said.

He added it was heartening that most Indonesians had seen the pictures and admitted that it disturbed them and made them uneasy.

The survey found more than 94 percent of the respondents said they had seen the graphic images.

“Indonesia has really managed to implement the pictorial health warnings throughout the country,” he said. “More than 90 percent of the respondents have seen them, this is very encouraging.”

Singh Bam said that people admitting the images made them feel uneasy was already enough to prove that the implementation of the pictorial health warnings was one of the most cost-effective health interventions to deter people from smoking.

“When people say they prefer to have cigarette packs without the health warnings it means the strategy works, the images scare them,” he said.

Khanchit Limpakarnjanarat, the World Health Organization’s representative to Indonesia, said that the study showed that the implementation of the pictorial health warnings was powerful in generating awareness and influencing decision makers.

“Although we still don’t have 100 percent compliance yet, the result is very encouraging indeed,” he said. “We need the data to support the fight because we have concluded that smoking is one of the major health risks in Indonesia.”

Despite government efforts to enforce the law, the survey found violations occurring, with the tobacco industry bending the rules to its benefits.

Santi Martini, a researcher for the study, said she found that many health warnings were not visible on packets because they were covered by cigarette excise stickers.

“This happens especially to machine-produced clove cigarettes,” said Santi, a  public health expert at Surabaya’s Airlangga University. “The image on the back side of the packs are frequently covered by the excise bands.”

Previously, Tulus Abadi, the operational manager at the Indonesian Consumer Protection Foundation (YLKI), said a survey conducted in four major cities found that 66 percent of popular cigarette brands had their warnings concealed under the excise stickers.

Tulus said imported cigarette brands had been found to have lower compliance compared to local products.

He alleged that the tobacco industry had made a secret deal with officials in the tax office to print larger excise stickers to cover the health warnings.

Tommy Hutomo, an official with the Finance Ministry’s Directorate General of Taxation, denied the allegation.

He said concerns about the cigarette producers placing the stickers in such a way to conceal the graphic warnings had been discussed thoroughly prior to the issuance of the 2012 government regulation on tobacco control.

The stickers are typically placed along the back and side of the pack; the warnings, meanwhile, are on the front and back faces of the pack.

“The law requires that cigarette excise bands should be applied to the top flap of the cigarette pack so that it tears when the pack is opened,” Tommy said, adding that the excise bands needed to be damaged to ensure that they could not be reused.

He also denied that the size of the excise bands had been made bigger to cover parts of the image.

“There has been no change of the excise band size in the past 10 years; we did not make it bigger on purpose,” he said.

The Health Ministry says trying to curb the number of smokers in Indonesia, where two out of every three adult males are active smokers, is a tall order.

“We have been disseminating all kinds of information at the district level but the fight is very hard because the tobacco industry seems to be invincible,” said Lily Sulistyowati, the ministry’s director of health promotion.

But she said the ministry was optimistic that Indonesia would be able to increase the size of the health warnings to 90 percent of the packs by 2019.

“What we’re aiming for is plain packaging. But we cannot fight alone,” Lily said.