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Health warning label: starting point for tobacco control
The tobacco industry in Thailand was formerly a monopoly operated by the Thailand Tobacco Monopoly (TTM). From 1989 to 1991, Thailand was pressured by the transnational tobacco companies (TTCs) to liberalise the tobacco trade. The TTCs asserted that banning foreign imports was contrary to the Charter of the General Agreement on Tariffs and Trade (GATT) (now the World Trade Organization). The GATT concurred, but ruled that Thailand could maintain its tobacco control policies as long as they were equally applied to domestic and imported products. Therefore, in 1992, the Thai government, through the Ministry of Public Health (MOPH), issued the 1992 Tobacco Products Control Act.1–3 Among other measures, the Act mandated health warning labels on tobacco product packaging. In the first phase, six different warning messages were to cover 25% of the front and back of the tobacco package. In 1997, the area was expanded to 33.3% (see figure 1).
Pictorial health warnings
Thailand was the first country in the Asia and Pacific region to join the WHO Framework Convention on Tobacco Control (FCTC), in 2003. In 2005, to implement Article 11 of the FCTC, the MOPH issued a policy requiring one of six pictorial health warnings (PHWs) along with text on 50% of both the front and back of tobacco packs. TTM and TTCs unsuccessfully appealed to the MOPH to reverse the policy and Thailand became the fourth country in the world to replace text-only warnings with PHWs and to reduce the advertising space on tobacco packaging. In 2009, PHWs on the tobacco pack were expanded to 55% of the front and back (see figure 1).
In Thailand, there was no long-term plan for tobacco control policy because most politicians and government officials do not consider tobacco control a priority.4 Therefore, advancing tobacco control policy is a mission of tobacco control groups. In 2011, one of their missions was to increase the size of PHWs on tobacco packs, in accordance with the FCTC recommendation that each country should increase the PHWs as much as possible. Here, we describe the advocacy process that successfully advanced the policy, including : building the advocacy team; analysing the situation and stakeholders; countering tobacco industry arguments, and developing a media advocacy strategy.
Preparing to fight: 85% PHW advocacy process
Building the advocacy team
The advocacy team focused on strategic planning activities, such as data preparation and communication. It included the leaders of tobacco control networks and the representatives of the Action on Smoking and Health (ASH) Foundation, the Thai Health Promotion Foundation, the Bureau of Tobacco Control under MOPH, the Thailand Health Promotion Institute, the Tobacco Control Research Center (TRC), the Health Professional Network Against Tobacco, Mahidol University, the Southeast Asia Tobacco Control Alliance (SEATCA), the Teacher Network Against Tobacco, and the Youth Network. The team was led by Dr Prakit Vathesatogkit, the secretary of ASH. The leaders from the aforementioned agencies were selected to work on behalf of the advocacy team and divided the work into subteams (see table 1).5
Because PHW was a sensitive policy in Thailand and affected the TTCs, advocates began the campaign by approaching the Public Health Minister directly, out of the public eye. There was no research specifically about Thailand to support further increasing the size of PHWs to 85%, but in meetings between the advocacy team and the Minister of Public Health, the advocacy team used the case studies of large PHWs in other countries such as Brunei, Canada, Uruguay, and Australia.6 The Minister worried that TTCs would sue but the advocacy team convinced the Minister that if they did sue, they would lose.7 Therefore, in March 2013, the Minister of Public Health signed a policy that increased the PHWs to 85% of the front and back of the package, specified 10 warning labels, and required inclusion of contact information for the national Quitline. The policy was to become effective on 2nd October, but the TTCs sued the Minister in June 2013 to force its reversal. Subsequently, the Administrative Court issued an injunction to suspend enforcement of the policy until the Court reached a final ruling.8
Situation and stakeholder analysis
This was the first time the TTCs had sued in Thai courts and the lawsuit served as inspiration for beginning a new policy advocacy process. The advocacy team therefore developed the following situation and stakeholder analysis to guide their next steps.
Setting the goal, target audience, and communication strategy. The analysis established that the primary goal should be countering the allegations of the tobacco industry to both the public and policymakers in order to gain their support. The primary stakeholder was the Administrative Court, which holds hearings, but may also consider other forms of evidence, including press coverage or surveys of the public, in order to inform its decisions. Other stakeholders identified in addition to the public included policymakers such as the Ministers of Justice, Education, and Finance. Key opponents, in addition to the TTCs, included the TTM and the Association of Tobacco Farms. The situation analysis established that the main goal was to win the court battle and to get an order from the court to enforce the policy. Mass media was the primary communication tool for providing facts about the effectiveness of expanding the PHW.
Finding empirical evidence to support the policy. If the fight for the policy were to be successful, the information to be communicated to the authorities and the public was that the expanded PHW would decrease smoking prevalence, especially among young people, by reducing the number of new smokers.
Identifying weaknesses in the tobacco control community. At that time, there was no network to support the policy. Therefore, the National Alliance for Tobacco Free Thailand (NATFT), which included respected medical experts, was established. Later, it played a major role in supporting the policy, such as holding a press conference to support the expansion of the PHW. The leaders of the NATFT also met with and supported the Minister being sued by the tobacco industry.
Finding information to counter the allegations of the tobacco industry. The tobacco industry criticised the policy on various grounds, claiming, for example, that the 85% PHW would obstruct their trademarks; that there was no evidence that the policy would reduce smoking prevalence; that the policy was burdensome for convenience stores and retailers; that the policy destroyed tobacco farmers; and that there had been no opportunity for the public sector and other stakeholders to comment.
Countering tobacco industry arguments
The communication principle to counter the tobacco industry was to focus attention on the effectiveness of the policy at decreasing tobacco use, not necessarily to respond to every issue. Another communication principle was the selection of a reliable communicator who had experience as a tobacco control advocate, as well as relying on academics from the TRC. See table 2 for a summary of tobacco industry statements and tobacco control responses that appeared in Thai newspapers in 2013.
Developing a media advocacy strategy
The advocacy team created a key message: ‘I Support 85%! Tobacco kills, it is not an ordinary product’. This message was used to guide media advocacy and communicate through the various channels. Communications focused on policymakers, the court and the public in order to distribute evidence to counter the tobacco industry and to call for social support. Multiple communication channels were used.
(1) Mass media such as press releases, television and radio programme interviews, and special newspaper articles were a primary channel. These were used to clarify the necessity of the policy and to counter the arguments that the tobacco industry used. The advocacy team believed that the most successful and efficient communication channel was mass media, especially television, which plays an important role in agenda setting in Thailand.9 10 Policymakers followed social trends by watching TV news.
The advocacy team created events that would play well on television. For example, the Youth Network held a protest rally in front of Philip Morris International (Thailand) offices to demand they withdraw the lawsuit. Also, ASH and NATFT hosted a press conference to support 85% PHW. These events were reported by major newspapers and the key message was published in the media. Moreover, newspapers quoted the advocates’ messages (e.g., that the FCTC allowed the Minister to implement the policy) without also quoting the tobacco industry (see figure 2). The team also made spokespeople available for news programme. When the campaign did not get coverage, the team used their media connexions to call for stories about advocacy activities. There was no formal evaluation to measure media reach but the advocacy team collected news clippings of the advocacy activities.
(2) Special events were also held and promoted, such as press conferences publicising research results that supported the policy, a seminar to educate Thai lawyers organised by an Australian legal expert who had been sued by the tobacco industry, and a forum discussion about the legal arguments that the tobacco industry used. Activities to support the Minister who was being sued were also organised. For example, the president of NATFT met with and gave flowers to the Minister to show solidarity with him.
(3) Online media such as Facebook, and the Change.org website were utilised, focused on communicating the necessity of expanding the PHW from 55% to 85%.
(4) Special media such as a White Paper conveyed supporting facts and countered tobacco industry arguments.
Response to advocacy
Before the policy was established, there was no grassroots support. Public support came after the TTCs filed their lawsuit, when the advocacy team created an 85% PHW Facebook page and developed a policy brief.5 Public opinion polling and social media statistics showed that Thai people supported the 85% PHW plan. The policy brief was also used in communication with Ministers of Justice, Education and Finance, effectively neutralising them. Although there was no direct support from these Ministers, they did not oppose the policy. Most importantly, the effectiveness of this strategy was eventually affirmed by the court judgement. After considering various forms of evidence the advocacy team provided, the court agreed with the Minister’s decision to enforce the policy under the FCTC and agreed that increasing PHW to 85% would reduce smoking prevalence by more effectively communicating with youth and illiterate people about the dangers of tobacco. In July 2014, the Supreme Administrative Court cancelled the temporary injunction ordered by the Central Administrative Court, and the 85% PHW policy was put into effect. At the end of 2017, TTCs withdrew their lawsuit.
Although Thailand has had progressive tobacco control policies since the late 1990s, it is still fighting the tobacco industry. The advocacy team for tobacco control in Thailand learnt by doing. One lesson learnt is that advancing tobacco control policy is a difficult and complex task that requires reiteration and adaptation. The advocacy team first approached the MOPH directly, out of the public eye. Once the policy was in place and had been challenged by the tobacco industry, the team had to reassess and develop a public advocacy campaign. Second, the team was well coordinated and multidisciplinary, including tobacco control activists, health experts, communication experts, legal experts, and tobacco control researchers, who worked together for knowledge synergy. Third, the message was simple, clear, straightforward, and used consistently when communicating with the authorities, the media and the public. Finally, communications used an integrated media approach. Although the most powerful communication channel was mass media, the advocacy team learnt to use online media and social events as well to disseminate the key messages to policymakers and the court.
The authors would like to acknowledge The Thailand Research Fund and Office of the Higher Education Commission for providing financial support. The authors also thank the tobacco control networks in Thailand for their additional data, and Rajamangala University of Technology Thanyaburi for its facility assistance. In particular, the authors are grateful to Dr Elizabeth Smith for invaluable comments and suggestions on this manuscript.
Contributors NS contributed towards the overall content, development, review, writing and editing of this manuscript. PS provided substantial information and assistance while drafting this manuscript. All authors provided their final approval for its publication.
Funding This paper was funded by grant number MRG5980125 from The Thailand Research Fund and Office of the Higher Education Commission on the project of media advocacy for advancing public health policy in Thailand.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.