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Rates of smoking in the countries of the former Soviet Union (fSU) are among the highest in the world and the region has the highest accumulated burden of tobacco-related disease among men less than 75 years of age in the world.1–3 Smoking among men was already common during the Soviet era, when cigarettes were cheap and readily available. The collapse of Communism paved the way for transnational tobacco companies to use aggressive marketing campaigns, targeted particularly at women and youth.4 ,5 Rates of smoking appear to have stabilised in the region, but remain extremely high among men.6
This situation demands comprehensive and effective tobacco control programmes.3 ,7 However, tobacco control measures were virtually non-existent in the Soviet era and after the collapse of the Soviet Union, transnational tobacco companies actively obstructed progress in tobacco control.5 ,8 ,9 There has been some progress in the past decade, with all eight countries examined in this study either ratifying or acceding to the WHO Framework Convention on Tobacco Control (FCTC). Nevertheless, implementation of tobacco control remains a major challenge.3
Warnings on tobacco packaging are a key element of a comprehensive tobacco control strategy.3 ,7 Article 11 of the FCTC recommends that packaging should: (i) contain different (‘rotating’) warnings about the health effects of tobacco use, ideally including images, and which constitute 30% or more of the principal display area of the packet (and preferably exceed 50%); (ii) avoid the use of ‘deceptive’ labels such as ‘lights’ and ‘mild’; (iii) contain information on the constituents and emissions of tobacco products; (iv) have warnings and other information in the main principal language(s) of the country.7
In a previous study, we described the development of a standardised instrument for examining cigarette pack labelling and applied it to 12 countries in Asia, Europe, Latin American and Australia.10 In this study we extend this analysis to eight countries in the fSU. To the best of our knowledge, no such study has been conducted in any of these countries. Our aim is to analyse compliance of cigarette packets with the FCTC and national legislation and the policy actions that are required in eight former Soviet Union countries.
We undertook a series of nationally representative household surveys in Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Moldova, Russia and Ukraine, with samples of between 1800 and 3000 respondents in each country (further details of the survey methods are provided elsewhere6). In the surveys we asked smokers which brands they smoked and we then obtained packets of each of the 10 commonest brands in the eight countries. These were then analysed using the standardised data collection instrument we had developed previously.10 A total of 79 packets were collected from the eight countries and analysed (only nine were analysed for Armenia as duplicate brands were collected there).
All panels of each package—front, back, top, bottom, sides and inside—were assessed and the exact content, location and size of all health warnings, promotional, legislative and constituent labels recorded (eg, see online supplementary file). The front and back panels were considered the principal display area as per the FCTC, and analysed separately as the front display area is considered the most visible to the user. All labels were translated into English. Health warning labels were categorised as ‘specific’ (providing a detailed description about the health effects of smoking) or ‘general’ (eg, a Russian health warning of ‘smoking causes lung cancer’). The size of the health warning label was assessed and calculated as the area it occupied (height×width) divided by the principal display area (area of the front and back panels of the packet). Borders around the label were included as part of the label. The number of labels per pack was counted, whether they were in the main language of the country, and whether there was a pictorial warning. The presence of constituent labels and their contents was also documented. Deceptive labels figure 1 (eg, ‘lights’ in Russia, ‘activated charcoal filter’ in Azerbaijan) were assessed for their size (calculated in the same way as for the warning labels), their total number and location on the packet.
The summary findings are shown in table 1. There were health warnings on all the packets (with an average of two per pack in all countries) and the warnings were present on the principal display area (front or back) of 98% of the packets. The health warnings on the front and back panels met or exceeded the FCTC minimum recommendations for being 30% or more of the principal display area in all countries except Azerbaijan (6% front, 5% back) and Georgia (28% front and back), but no packets exceeded the preferred 50% suggested in the FCTC except the back panel in Russia (52%). All countries used a variety of warnings, except Azerbaijan where all the packets stated ‘smoking is harmful for your health’. All packets in all countries had warnings in the main language of the country. Compliance with recommendations on health warnings was weak in that no packets in any country used images and all messages were ‘general’ rather than ‘specific’. Also, while all packets displayed the chemical constituents (tar and nicotine), Russia was the only country that also presented the amount of carbon monoxide levels per cigarette.
The main area of non-compliance with FCTC was the use of deceptive labels, seen in 57% of packets (average 2.4 per packet). All deceptive labels were in the main language of the country.
Concordance of national legislation with FCTC recommendations and adherence of the packets assessed with national legislation is shown in table 1. National legislation on warning label size met or exceeded the FCTC recommendations in all countries except Azerbaijan which had no corresponding legislation. Warning labels in the main language were mandated in all the countries except Kazakhstan and Ukraine. Rotating health warnings were mandated in all countries except Azerbaijan, Belarus and Kazakhstan. Description of constituents was mandated only in Armenia and Kazakhstan. All countries except Azerbaijan and Russia banned deceptive labels as described in the FCTC. In addition, displaying a Quitline telephone number on the tobacco pack was required in Georgia (but no packets in Georgia provided this information).
All of the countries were close to meeting the FCTC minimum recommendations and national legislation on health warning labelling, with the exception of Azerbaijan. However, the health warning labels were below the 50% proportion of the principal display area recommended by the FCTC (except back panels in Russia). Gaps in national legislation on health messages which need to be addressed include requiring messages to be in the main language(s) in Ukraine and Kazakhstan and the use of rotating messages in Azerbaijan, Belarus and Kazakhstan. Importantly, deceptive labelling was found on packets from all countries. This contravened the FCTC recommendations, as well as national legislation except for Russia and Azerbaijan which have thus far failed to introduce legislation banning their use and urgently need to address this policy gap. Stopping deceptive labelling should be a policy priority given the high public misunderstanding of such labelling in the region.12
These findings are similar to those from our earlier study of 12 countries in Asia, Latin America, Europe and Australasia which noted adequate compliance with health warning labelling, but weak national policies and compliance on deceptive labelling.10 There is a clear need to enforce FCTC recommendations and strengthen national legislation as the existence of deceptive labelling undermines the effects of health warning labels. The most effective packaging control policy would be a standardised, plain tobacco packet.13 ,14
The findings highlight the need for closer surveillance by fSU governments. WHO country reports need to be strengthened; they currently provide only limited information on FCTC compliance and do not involve systematic packaging analysis. This could be done by partnering with civil society organisations to produce ‘shadow’ reports on FCTC compliance, as done elsewhere.15
The main limitation of our study is that we only assessed the 10 leading brands in each country and in some countries many more brands were smoked (eg, the brands assessed in Russia were smoked by 35% of smokers, while in Azerbaijan they accounted for 71% of smokers). In addition, we only assessed nine brands in Armenia rather than 10.
The strengths of the study include building on a household survey which helps ensure that we have assessed the most popular brands. Our use of the same instrument provides a means of comparing our findings with those from other parts of the world. It also permits assessment of changes over time and so contributes to strengthening ongoing surveillance to help address the persisting gaps in compliance of cigarette packaging. Studies show widespread popular support for tobacco control in the region,12 ,16 ,17 and national and international policy makers should respond to this public sentiment by strengthening, monitoring and enforcing policies to strengthen packaging compliance with FCTC and national legislation in the fSU.
What this paper adds
Controls on cigarette packaging are a key tobacco control measure.
This paper provides the first analysis of cigarette packaging for the 10 most popular cigarette brands in each of eight countries of the former Soviet Union and an evaluation of how this packaging complies with FCTC and national legislation.
The findings highlight a number of gaps in compliance and provide valuable evidence to help strengthen tobacco control measures in the region.
We are grateful to all members of the Health in Times of Transition Project (HITT) study teams who participated in the co-ordination and organisation of data collection for this paper.
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
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