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Abstract
Objective To critically review the structure of tobacco control policy making in China, examine conflicts of interest within this structure, and consider how these affected the introduction of on-pack warnings.
Methods Government policy documents and warning labels were obtained and critically reviewed.
Results Few differences exist between the on-pack warnings formerly used in China and those introduced ostensibly to meet Framework Convention on Tobacco Control (FCTC) obligations. Comparison with tobacco manufactured for export or overseas consumption shows the new Chinese domestic on-pack warnings are demonstrably inferior to those required internationally. The inherent conflict of interest in the Chinese tobacco control agency structure, which must meet commercial and public health objectives, undermined the introduction of new health warnings.
Conclusions To promote more effective tobacco control policies, the conflict of interest inhibiting the public health function of the State Tobacco Monopoly Administration (STMA) must be removed. Specifically, the public health function must be separated from oversight of commercial production, and packaging must be redesigned with pictorial warnings and messages compliant with Article 11 of the FCTC.
- Cigarette packaging
- health warnings
- FCTC
- China
- harm reduction
- packaging and labelling
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Introduction
In 2005, 8.5 million people died in China1; of that total, about 1.2 million deaths were attributable to tobacco use.2 Six out of the leading eight causes of death in the Chinese population,3 namely stroke, chronic obstructive pulmonary disease (COPD), coronary heart disease (CHD), lung cancer, gastric cancer and oesophageal cancer, were linked with tobacco use.2 Smoking prevalence is 28.1% in China, representing 301 million people.4
Ironically, although much is known about the measures that can reduce smoking prevalence, these measures have not always been applied effectively and, in some instances, have not been applied at all. In China, one compelling example of this problem is the introduction of on-pack health warnings.5
Many researchers have outlined the importance of on-pack health warnings as these reach smokers whenever they wish to smoke and can also influence non-smokers, who observe packaging in social situations.6–8 An average smoker see on-pack warnings 20 times per day, which amounts to more than 7000 exposures each year.7 In addition to reaching smokers at the point of decision making, on-pack warnings may influence whether they decide to smoke. Warnings are more likely to promote cessation-related behaviours if they have strong visual impact and stand out from the…brand imagery that otherwise dominates tobacco packages.6
Pictorial health warnings (PHWs) achieve high salience by providing graphic representations of the harms caused by tobacco. The International Tobacco Control (ITC) four-country survey shows cigarette packages featuring PHWs are the most prominent source of health information.8 There is now compelling evidence that PHWs are an important means of communicating the harm caused by tobacco to the public.9 ,10
Article 11 of the Framework Convention on Tobacco Control (the FCTC) provides detailed requirements for health warnings on tobacco products.11 Specifically, the implementation guidelines recommend that health warnings on cigarette packages show the harm of tobacco use, are large, clear, visible and legible, and cover 50% of display area and not less than 30% of the pack surface.12 These attributes help ensure PHWs are visually prominent, thereby promoting widespread understanding of the health effects, addictiveness and lethal consequences of tobacco consumption and exposure to secondhand tobacco smoke.
The Chinese government signed the FCTC on 10 November 2003; to honour this commitment to the FCTC, China needed to implement new health warnings on cigarette packages by 9 January 2009. The Chinese Ministry of Industry and Information Technology has lead implementation of the FCTC via the State Tobacco Monopoly Administration (STMA). However, in addition to developing and implementing tobacco policy, including on-pack warnings, the STMA also has responsibility for the China National Tobacco Corporation (CNTC), which is the largest single manufacturer of tobacco products in the world.13 Several researchers have noted that these dual roles create a conflict of interest that could potentially undermine tobacco control efforts.13 ,14
These dual responsibilities raise important questions about the organisation of tobacco control authorities and whether structural attributes impede their ability to protect consumers. Therefore, there is a need to examine whether the newly designed cigarette packages in China meet FCTC requirements and can appropriately warn the public of the harm attributable to tobacco use. As part of the ‘Towards A Smoke-free China’ project funded by the Bloomberg Philanthropies and ‘Epidemiology and Intervention Research for Tobacco Control in China’ funded by National Institute of Health in the US, we analysed China's former and new warnings, and compared these to the warnings displayed on foreign cigarette packages. We begin by reviewing the Chinese tobacco control structure before analysing its effects on the implementation of on-pack tobacco warnings. We conclude by offering recommendations that would promote more effective tobacco control policy and afford greater protection to Chinese citizens.
Methods
Tobacco on-pack warnings
On 2 April 2008, the STMA and the General Administration of Quality Supervision, Inspection and Quarantine, jointly released the Regulations on Cigarette Packaging and Labelling in the Territories of the People's Republic of China (the Labelling Regulations). These regulations took effect in January 2009 and applied to all domestically produced cigarettes and all foreign imported tobacco products.15 Article 3 of the guidelines state:
Article 3 The health warning messages on the cigarette packaging should be printed in standard Chinese characters of the People's Republic of China and in English. There are two sets of health warning messages:
Group 1 SMOKING IS HARMFUL TO YOUR HEALTH QUIT SMOKING REDUCES HEALTH RISK
Group 2 SMOKING IS HARMFUL TO YOUR HEALTH QUIT SMOKING EARLY IS GOOD FOR YOUR HEALTH
Article 3 sets out the two health warnings that will be rotated on Chinese tobacco packages for domestic use and illustrates their dual components: a warning that smoking is harmful, and encouragement to quit early and thus reduce the risk of those harms eventuating. Article 4 requires the warnings to be rotated, while Article 5 notes where they should appear (front and back of packs and cartons) and stipulates that the warning must cover at least 30% of the pack or carton surface.15
A closer review of the Labelling Regulations reveals discrepancies with key requirements of Article 11 of the FCTC.5 ,9 First, the FCTC requires health warnings to cover one-third of the display area. However, the Chinese regulations only require a line to mark one-third of the display area, while the warning text itself covers substantially less than one-third of the display area. Although the warnings now feature on the front of the pack rather than the side, as was the case previously, the warnings remain less prominent and impactful than if they had covered the allocated 30% surface area. Figure 1 illustrates this problem.
Old style (prior to October 2008) and new style (post October 2008) health warnings on cigarette packages in China.
As figure 1 demonstrates, the new Chinese on-pack warnings fall well short of the FCTC requirements. According to the legally binding Article 11 of the FCTC signed by China, warning signs should cover 50% of the overall display area. However, Chinese regulations require only 30% coverage; furthermore, the warnings appear in tiny characters, raising questions about their legibility and potential impact.
Second, the health warnings do not specify the health consequences of smoking. The regulations require only two sets of messages (set out above), neither of which provides information about the myriad risks of smoking. Several studies have concluded that, while smokers report they know the health hazards of tobacco, few truly appreciate the specific harm tobacco can cause.16 That is, while most smokers may understand at a general level that smoking poses health risks, far fewer can identify those risks, and fewer still understand and personally accept the implications of those risks.
Communicating only very general risk information means the content of the new Chinese warnings fails to meet FCTC requirements, which stipulate that health warnings must describe the harm tobacco can cause. While the Chinese warnings provide information about the general harmfulness of tobacco and smoking, they provide no information about the specific harms caused by smoking and arguably neither promote smokers' knowledge of the risks they face nor meet FCTC requirements.17
Third, the general messages featured in the warnings have already become saturated among the public in China,18 a fact that reduces their likely impact on smokers. Pictorial warnings may play an important role in promoting more detailed knowledge and understanding of smoking's risks.7 Evidence suggests PHWs are more informative and have stronger effects on cessation and initiation deterrence than text only warnings.19 ,20 In addition, recent evidence from China suggests the new warning labels were markedly less effective than PHWs.21
Furthermore, FCTC Article 11 guidelines point out that health warnings containing text and pictures are more effective than purely text warnings.12 Countries such as Australia, Belgium, Brazil, Canada and Thailand have found that strong cigarette package health warnings, especially those including pictorial information, are an important way for young people and people with lower literacy to obtain information.22
In addition, half the messages are in English, a language most Chinese smokers do not understand. A recent survey shows that 73.2% adult Chinese smokers cannot translate ‘Smoking is harmful to your health’ correctly, and 89.9% of smokers cannot translate ‘Quitting smoking early is good for your health’ correctly.23
As figure 1 illustrates, the warning text is only 2 mm high…and therefore is even smaller and less visually salient than the font used in the previous warning messages. Furthermore, Article 5 allows warnings to use the same background colour as the main pack surface, thus the messages are not visually distinguished from the on-pack branding. Integration of the warnings with the package branding greatly reduces the warning salience, and thus the likelihood that smokers will notice, consider or act on the health messages provided.
Overall, the domestic regulations on cigarette package abelling fail to comply with Article 11, thus the STMA is effectively hampering the public's ability to learn about the harm caused by tobacco. Comparison with international practice further illustrates the discrepancy between China's implementation of Article 11 and other countries' response to their FCTC obligations. Figure 2 contains images of the new packs (picture A) and compares to these packs manufactured for export (picture B), and packs sold in other countries (picture C24).
New style Chinese pack for export and international on-pack warnings.
Among the three pictures, the Chinese packs manufactured for export have considerably larger and more salient warnings than the new Chinese warnings, and incorporate graphic images on the front and back of pack surfaces. The export packages are more directly comparable with warnings used in other countries, such as the Australian warnings shown in the final column.
It is clear that China's cigarette packages, whether new or old, are unlikely to be noticed by smokers and are even less likely to influence their behaviour. However, packages of Chinese cigarettes produced for export markets and packages of foreign cigarettes sold overseas have more visually impactful warnings that research suggests will more effectively reduce tobacco consumption by smokers, enhance awareness and motivation to quit, and help prevent those who have managed to quit from starting again.10 ,21 ,25
Discussion
Cigarette packages featuring prominent PHWs that communicate harms caused by tobacco are among the most cost-effective means of warning smokers and potential smokers about the risks they face.8 ,26 WHO research shows pictorial warnings are a stronger deterrent than text warnings, and recommends PHWs as best practice on-pack warnings.22
However, despite the potential PHWs offer, and irrespective of China's status as a signatory to the WHO FCTC, Chinese regulations have fallen far short of FCTC standards. This failure appears attributable to the conflict of interest that undermines the public health role of the STMA, which oversees tobacco production and distribution, and public health policies relating to tobacco control.
As a government agency, the STMA is obliged to undertake tobacco control and implement the FCTC. Yet it is simultaneously a tobacco company, with all the commercial responsibilities of promoting its profit-oriented objectives. These two roles, which at the same time require the STMA to promote and limit tobacco consumption, are irreconcilable.
Furthermore, this dual role ensures the tobacco industry has a prominent role in developing public health policy since, when Chinese government officials discuss tobacco control, tobacco company representatives are also present. When interviewed by the International Herald Tribune, Patricia Lambert, Director of International Legal Consortium, the Campaign for Tobacco-Free Kids said, ‘It is like inviting the fox to sit in the chicken cage and discuss how to protect the chickens’.27
Public health objectives will not be served while industry representatives shape the policy within which they must operate. The only response to this anomalous and illogical structure is to redefine the Ministry of Industry and Information Technology's role, ensure tobacco control policy development is chaired by public health experts, and separate the STMA's functions from those of the CNTC. So long as the STMA remains linked to the CNTC, it cannot be involved in FCTC implementation and coordination.
The separation we have proposed should be followed by a regulatory review. Specifically, the Labelling Regulations announced by the STMA should be rescinded, and cigarette packages redesigned to contain PHWs with warning messages and graphic imagery. Anything less would leave China in breach of its FCTC obligations.
Conclusions
We strongly recommend that the STMA become an independent tobacco industry regulator, responsible for tobacco industry policymaking, macro management and oversight of tobacco companies, and that its responsibilities for tobacco manufacturing and distribution cease. At present, the STMA and the CNTC are effectively the same organisation, albeit operating under two different names. Conflating regulatory roles with corporate responsibilities creates confusion, which tobacco companies exploit to the detriment of Chinese citizens.
What this paper adds
In China, the State Tobacco Monopoly Administration manages tobacco control measures designed to reduce smoking prevalence, but is also responsible for meeting commercial tobacco supply objectives.
We analyse this inherent conflict of interest, which has impeded implementation of the FCTC, failed to meet the criteria outlined in Article 11 and left Chinese people, of whom 301 million smoke, inadequately informed of smoking's harm.
We recommend the STMA become an independent tobacco industry regulator, responsible for tobacco industry policy-making, macro management and oversight of tobacco companies, and that its responsibilities for tobacco manufacturing and distribution cease.
References
Footnotes
Funding Funding was received from the Bloomberg Initiative to Reduce Tobacco Use (870-2233) and NIH project ‘Epidemiology and Intervention Research for Tobacco Control in China’ (R01 RFA-TW-06-006).
Competing interests None.
Ethics approval This study was conducted with the approval of the Institute of Basic Medical Sciences of Chinese Academy of Medical Sciences.
Provenance and peer review Not commissioned; externally peer reviewed.