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Sychareun et al. BMC Public Health (2015) 15:1094 DOI 10.1186/s12889-015-2415-9

RESEARCH ARTICLE

Open Access

Perceptions and acceptability of pictorial health warning labels vs text only - a crosssectional study in Lao PDR Vanphanom Sychareun1,3*, Visanou Hansana1, Alongkone Phengsavanh1, Kongmany Chaleunvong1 and Tanja Tomson2

Abstract Background: In Lao PDR, health warnings were first introduced with printed warning messages on the side of the cigarette package in 1993 and again in 2004. Lao PDR same year ratified the Framework Convention on Tobacco Control (WHO FCTC) but has not yet implemented pictorial health warnings. This paper aims to examine the perception and opinion of policymakers on “text-only” and “pictorial” health warnings and to understand lay people’s perceptions on current health warnings and their opinions on the recommended types of health warnings. Methods: A combination of quantitative and qualitative methods were used in this cross-sectional study conducted in 2008. A purposive sample of 15 policymakers, and a representative sample of 1360 smokers and non-smokers were recruited. A range of different areas were covered including consumer attitudes towards current and proposed cigarette package design, views on health warning messages on the flip/slide and inserts, and views on the relative importance of the size, content and pictures of health warning messages. Descriptive statistics and content analysis were used. Results: Policy makers and survey respondents said that the current health warning messages were inappropriate, ineffective, and too small in size. All respondents perceived pictorial health warnings as a potentially powerful element that could be added to the messages that can communicate quickly, and dramatically. The majority of policymakers and survey respondents strongly supported the implementation of pictorial health warnings. The non-smokers agreed that the graphic pictorial health warnings were generally more likely than written health warnings to stimulate thinking about the health risks of smoking, by conveying potential health effects, increasing and reinforcing awareness of the negative health effect of smoking, aiding memorability of the health effects and arousing fear of smoking among smokers. Conclusions: The study suggested that current warnings are too small and that content is inadequate and designed to be hidden on the side pack. These findings are in line with FCTC’s requirements and provide strong support for introducing pictorial warning labels also in Lao PDR. Furthermore, the awareness of Members of Parliament about tobacco control measures holds promise at the highest political level. Keywords: Tobacco, Smoking, Health warnings, Awareness, Policy makers, Lao PDR

* Correspondence: [email protected] 1 University of Health Sciences, Faculty of Postgraduate Studies, Vientiane, Lao PDR 3 Faculty of Postgraduate Studies and Research University of Sciences Vientiane, P.O. Box 744, Vientiane, Lao PDR Full list of author information is available at the end of the article © 2015 Sychareun et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Sychareun et al. BMC Public Health (2015) 15:1094

Background In Lao People’s Democratic Republic (Lao PDR), health warnings were first introduced in the country in 1993 with printed warning messages on the sides of the package of the cigarettes in the Lao language. The first brand of cigarettes was “Laimthong” followed by “Dok MaiDaeng”, whith the health warnings in English. The Marlboro and L&M cigarettes carried health warnings in both the Lao and English languages at the bottom of the front of the package. There are two big tobacco companies in Lao PDR, namely Lao-China Lucky Tobacco Company Limited and Lao Tobacco Company Limited, producing the two most popular brands of cigarettes: A Deng and Dok MaiDaeng (Red Flower) [1]. From 2003 to 2014, the Ministry of Health (MoH) also developed health warnings describing the hazards of smoking such as “Smoking is dangerous to health” in Lao and “do not sell tobacco to children under 18 years old” which were printed on the cigarette brand “555”. The aim of health warnings on tobacco products was to provide information about the health risks of smoking, the benefits of quitting, and to motivate people to quit [2]. In June 2004, Lao PDR ratified the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), the first global tobacco control treaty. According to the FCTC, health warnings are required. Specifically, Article 11 states that the health warnings should be large, clear, visible, legible, and “should” cover 50 % or more, but no less than 30 % of the total display areas and may include pictures [3]. According to the labeling of Tobacco Product Containers Regulations, the health warnings on cigarette packages must be in Lao language and 6 warnings (Fig. 1) are to be carried in rotations approved by the

Fig. 1 Current Health Message of Health warnings

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Ministry of Health, (MOH) No 660/MOH dated 23 November, 2006 [4, 5]. According to the Tobacco Law endorsed in 2009, labels are texts determined by the government and printed on front and back sides of each packet, parcel, carton and case to show tobacco users that this product is dangerous and harmful to human health [6]. The tobacco companies in Lao PDR continue to ignore the health warning regulations. While the deadline for Lao to comply with the FCTC Article 11 was December 2009, Lao is pushing for a decree to help enforce the tobacco companies’ compliance with the regulations. These warnings were to be displayed in bold, white, letters in Saysetha Lao font with a size of 20, and on a black background covering the lower 30 % of the two largest surfaces of the packet. In the case of imported cigarettes, this should follow the current regulations of Lao PDR, should include key messages, and should cover 50 % or more of the displayed areas. More than 50 countries have adopted the FCTC recommendation for pictorial warnings that cover at least half of the package [7], but not Lao PDR [4]. Countries such as Canada, Brazil, Poland and Australia have already introduced graphic warnings through new legislations in this area, using more prominent messages and pictorial images. Previous research has suggested the role of on-pack messages as a valid health communication tool. A survey carried out in Australia [8] reported that health messages on cigarette packs resulted in an increased probability that the warning is noticed, and made smokers more likely to consider negative consequences. Pictorial warnings are also necessary, particularly in countries with low literacy rates or where research shows smokers are ignoring standard warning labels. In Lao PDR the smoking prevalence among males is 43.1 %, and for females 8.4 %. The prevalence of smokeless tobacco was 7.9 % among female adults and 1 % for male adults [9]. Previous studies have shown that smokers in countries where a warning depicts a particular health hazard of smoking (e.g., impotence) are much more likely to know about such hazards [10]. Health warnings are important because they play a role in educating and informing smokers, especially young smokers, of the health risks of smoking (Elliot and Shanahan. Evaluation of the Health Warning Labels on Tobacco Products and Evaluation of the Commonwealth’s Information Line, prepared for Drugs of Dependence Branch, Commonwealth Department of Health and Family Services. unpublished). Previous studies highlight the potential of on-pack health information to inform smokers of the hazards of smoking, and to encourage quitting and to disrupt tobacco brand imagery [11–13]. Thus, the principle of large, picture-based warnings has been accepted on five continents. Amongst other advantages such warnings allow the chance to reach more vulnerable groups including women and children of smokers [14].

Sychareun et al. BMC Public Health (2015) 15:1094

In order to minimize the disease caused by smoking, efforts need to be taken to make people aware of the consequences of smoking such as lung cancer, heart disease, stroke and to ensure that the most effective method is chosen to do this. Hence health warnings need to be designed and tested in order to recommend effective health warnings to the health policymakers. In addition, new regulation of health warnings describing the effect of tobacco use and pictorial warnings on all of tobacco products should be implemented in order to generate awareness of the hazards of smoking. To our knowledge, this is the first study on cigarette package health warnings in Lao PDR. Our aim was to examine perceptions and of, and responses of pictorial and text health warnings among policymakers, members of parliament and the general public. The specific aims of this study were to: 1) describe perceptions of current textonly health warnings by smoking status, 2) examine the perceived effect of text-only health warnings by smoking status, and 3) to assess the perceived effectiveness of the pictorial health warnings as compared to text-only warnings.

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Data collection In-depth interview of policymakers

A qualitative research methodology [15] was used to assess the perception and opinion of policymakers on health warnings on cigarette packs and the response of the pictorial design of tobacco health warnings. Qualitative in-depth interviews were used. The key informants were policymakers such as Members of Parliament who were chosen using purposive sampling. Initially, we recruited about 15 members of parliament from different ministries such as health, education, agriculture, culture, commerce and trade, and finance. However, the parliament members were not representatives of the ministries but were more representative of their provinces. In total, 15 parliament members from 14 out of 17 provinces were recruited for the study, with the exception of parliaments from Lunagnamtha, Champassack and Khammouane provinces. The key-informants were interviewed in Vientiane Capital during their Assembly meeting and they were asked about their opinion and attitudes regarding current health warnings, the most effective way of labelling tobacco to discourage smoking, and their opinion regarding the printed pictorial health warnings. Survey of smokers and Non-smokers-Lay people

Methods Setting/study site

Lao PDR (Laos), a lower middle-income country, has 17 administrative provinces, one capital city and a population of 6,7 million. Target focus groups and testing were conducted in the Vientiane Capital City. The main reason for selecting this study site is that many government and non-government facilities and the National Assemblies are concentrated in Vientiane. In addition, there are many manufacturing factories, including those of the tobacco industry. Moreover, there were also some data available of the prevalence of smoking in Vientiane Capital city, which consisted of 4 urban districts (Chanthabury, Saysetha, Sisattanak, Sikhottabong) and 5 semi-urban and rural districts (Xaythany, Naxaythong, Hadxayphong, Santhong, Pakgnum). The Sikhottabong and Chanthabury districts were randomly selected as urban districts and Xaythany and Naxaythong districts were randomly included as semi-urban and rural districts. This mixed-method study combined quantitative and qualitative research and covered a range of topics including consumer attitudes towards current and proposed cigarette package design, views on health warning messages on the flip/slide and inserts, and views on the relative importance of the size, content and pictures of health warning messages. Two different sub-studies were conducted: i) exploring the perceptions of policy makers; and ii) a survey of smokers and non-smokers.

The aim of the survey of smokers and non- smokers was to capture their understanding of current health warnings and their view of the preferable type of health warnings, including format, colour and graphics, position and coverage, rotation and inserts, and other information (Additional file 1). The target groups were adults aged 15–55 years of age. In total, 1360 participants were recruited (Table 1). They were selected in public places such as shopping centres, public parks, markets, restaurants, sporting venues, and entertainment venues. This method allowed us to approach target groups from different backgrounds. We changed location daily when recruiting participants. The respondents were approached privately, the purpose of the study was explained to them and they were then invited to participate in the study. The quantitative questionnaires included a brief section on socio-demographic background, followed by questions about perceptions of existing health warnings, as well as pictorial health warnings, the size of these warnings and key messages they contain. The guideline for interviewing policy makers composed of the sociodemographic characteristics, perception of existing health warnings and the future implementation of pictorial health warnings in Laos. To get the views of the participants on pictorial warnings, the research team showed them 10 mock packs adapted from different countries such as Thailand, Vietnam and other countries.

Sychareun et al. BMC Public Health (2015) 15:1094

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Table 1 Socio-demographic characteristics of respondents by smoking status Variables

Non-Smoker

Smoker

Total

N

N

N

%

%

P value %

Age (Mean = 32.42, SD = 13.68; Min-15, Max-55)

0.327

15-20

264

34.4

197

33.2

461

33.9

21-35

205

26.7

143

24.1

348

25.6

36-55

298

38.9

253

42.7

551

40.5

Gender