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REVIEW ARTICLE
Year : 2011  |  Volume : 55  |  Issue : 3  |  Page : 228-233  

Tobacco control: Lessons learnt in Thailand


1 Action on Smoking and Health Foundation, Thailand
2 Faculty of Public Health, Mahidol University, Thailand

Date of Web Publication16-Nov-2011

Correspondence Address:
Prakit Vathesatogkit
Executive Secretary, Action on Smoking and Health Foundation, 36/2 Pradipat 10, Phayathai, Bangkok, 10400
Thailand
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-557X.89938

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   Abstract 

This review of legislation, obstacles faced, and challenges to be met, outlines present tobacco control lessons learnt in Thailand. A review of over twenty years of tobacco control experience in Thailand is provided in seven areas including policy formulation and the role of civil society, as well as in essential WHO Framework Convention on Tobacco Control areas. A descriptive, historical review shows how stakeholders, policies and resources were mobilized in Thailand, and what lessons resource-challenged countries might use from the Thai experience.

Keywords: Framework convention on tobacco control, Policy, Tobacco control, Thailand


How to cite this article:
Vathesatogkit P, Charoenca N. Tobacco control: Lessons learnt in Thailand. Indian J Public Health 2011;55:228-33

How to cite this URL:
Vathesatogkit P, Charoenca N. Tobacco control: Lessons learnt in Thailand. Indian J Public Health [serial online] 2011 [cited 2019 Sep 18];55:228-33. Available from: http://www.ijph.in/text.asp?2011/55/3/228/89938


   Tobacco Epidemic in Thailand Top


Overall current tobacco use among all adults is 27.2% while 46.4% of males and 9.1% of females use tobacco in any form. Tobacco use is more prevalent in rural areas (29.2%) and among persons with a lower education level (33.4%). [1] Among 52.6 million adults, 20.5 million adults (39.1%) were exposed to second-hand smoke (SHS) at home. Among all employed persons who work in indoor areas, 27.2% were exposed to SHS at indoor areas of the workplace and among non-smokers who work at indoor workplaces, 23.6% were exposed to SHS at these workplaces. [1]

In 1991, about two decades ago, one in every three adult (32%) was smoking, and an insignificant proportion of women smoked (5%). [2] In the 1990s, the tobacco control effort in Thailand was in its inception. But over the years, the pace of tobacco control endeavors gained momentum and consequently the country saw a progressive decrease in the daily consumption of cigarettes. For instance, consumption of cigarettes decreased from 12 sticks per day in 2000 to 10 sticks per day in 2007. [3] However, Thailand still faces lots of challenges as equal proportions of people smoke manufactured cigarettes (7.87 million) and RYO cigarettes (7.4 million).


   Tobacco Control: Lessons Learnt in Thailand Top


Thailand is known as a country with substantial success in tobacco control over the past two decades. Many policy interventions have been adopted over the years. The smoking prevalence has gradually declined in the past two decades.

As in most countries, government inertia and tobacco industry activities hinder tobacco control. This review article outlines how policy legislation has been adopted, the obstacles encountered, how these obstacles have been overcome, and weak points and challenges remaining in several policy areas.

The policy formulation process

In 1989, the Thai Cabinet responded to civil society and health groups advocating for tobacco control policy by appointing the National Committee for the Control of Tobacco Use. This committee has been entrusted with policy formulation for tobacco control. The committee is chaired by the Ministry of Health with members from the ministry of finance, education, public relations, interior, independent experts in tobacco control, as well as media representatives. The expert and media representatives play very active roles in ensuring that the committee adheres to its mandate in making progress in tobacco control. No committee member from any ministry or other agency with a potential conflict of interest, such as representatives from the tobacco industry, ministry of trade or industry or farmers' representative was included. This committee structure is conducive to the formulation of tobacco control policy and in line with Article 5.3 of the WHO FCTC developed 20 years later; preventing the tobacco industry and its vested interests from interfering with tobacco control policy, formulation and implementation. [4] This National Committee has existed until present. The Tobacco Control Office within the Department of Disease Control, Ministry of Health serves as the secretariat of the National Committee on Tobacco Control.

The important lesson is that practically all the policy taken up for consideration by the committee was a result of well planned advocacy and lobbying by NGOs and experts in tobacco control working closely with the Tobacco Control Office within the MOH.

Advertising Ban

In 1992, the Parliament passed the Tobacco Product Control Act. The act banned advertising, promotion and sponsorship; "advertising" was defined as "an act undertaken by any means to allow the public to see, hear, or know a statement for commercial purposes." The act banned sale to persons under the age of 18 and sale by vending machine. The act also included provisions for health warnings and ingredient disclosure of tobacco products. [5]

In was considered to be very comprehensive legislation for its time, but the loophole was that it did not cover a ban of tobacco company names. The tobacco companies used their company name to sponsor art events and other activities. Civil society and antismoking groups now use social pressure to fight tobacco industries' so call 'corporate social responsibility' (CSR) activities, sometimes with and without success.

In 2001, the Minister of Health proposed and the Department of Public Relations responded by issuing a regulation to ban the "act of using tobacco products," or smoking scenes on TV. This regulation turned out to be very useful in that it practically prevented any smoking scene in any local programs produced for TV. It sent a strong signal to the show business industry that smoking in acting or in public provides a negative role model for the public. The problem faced was that the presence of smoking scenes in movies shown on TV used a mosaic technique (blurring) to cover the smoking act. One unresolved problem is that smoking scenes in movies transmitted live via satellite are not covered in the regulation.

In 2004, the Department of Public Relations, Prime Minister's Office response to the Ministry of Health proposal to issue regulations to ban tobacco companies from carrying out publicity of their CSR activities through electronic media, using the Television and Radio Broadcasting Act. The ban includes the use of tobacco company name and logo. The loophole remains that tobacco companies use print media and the internet to publicize their CSR activities.

At present, antismoking groups are trying to educate the public about the real intentions of tobacco company CSR activities as well as publicize WHO FCTC article 5.3 and article 13 recommendations so the country can ban these activities. [4] The Ministry of Health is in the process of proposing a draft bill to ban the use of tobacco company names to carry out CSR activities.

In 2005, the Ministry of Health issued an announcement to ban the display of cigarette packages at the point of sale [Figure 1]. This move was met with strenuous opposition by the tobacco companies who mobilized retailer associations to oppose the ban as well as challenging the clarity of the wording of the law. Antismoking groups had to come out in full force, mobilizing health groups as well as family networks and the media to support the Minister of Health to stand firm and not yield to tobacco company pressure. The 2009 Global Adult Tobacco Survey (GATS) shows that 6.7% of the over half a million retail stores still show cigarette packages or other advertisements.
Figure 1: Retail stores before and after the ban on point of sale displays of cigarette packages

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Remaining problems include advertising of internet sales and cross border advertising and depiction of smoking in movies shown in cinemas. The lesson learned is that the tobacco industry never stops violating the law and regulations on advertising/promotion and sponsorship and constant vigilance is necessary.

Health Warning on Tobacco Products

Thailand has had textual health warnings on cigarette packages since 1973 with several revisions to strengthen text and enlarge the size of the warnings. In 2005, graphic health warnings covering 50% of both front panels of cigarette packs was required. Thailand was the 4 th country to require graphic health warnings after Canada, Brazil and Singapore. The current third set of graphic warnings became effective in 2010, with the size of the picture increased to 55% on both sides and inclusion of the national Quitline number on each graphic warning [Figure 2]. Surveys show that graphic health warnings on cigarette packs are the second most important source of information that the Thai public receives on the health hazards of smoking.
Figure 2: 2010 Thai graphic health warnings occupy 55% of both sides at the top of cigarette packs

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The 2006 Ministerial Regulation required printing warning of cancer causing agents and toxic substances in cigarette emissions on 50% of both sides of the lesser panel of cigarette packs. Another ministerial regulation prohibits the use of misleading words such as light and mild as well as other misleading terms.

Over all, Thailand's regulations on tobacco product labeling conform with most of the details recommended in the Guidelines for Article 11 of the WHO FCTC. [4] Health groups are advocating for the Ministry of Health to adopt plain packaging regulations.

About half of Thai smokers smoke cheap hand rolled cigarettes. Graphic health warnings are not used by most of the small producers of loose tobacco for hand rolled cigarette. GATS shows that 39.7% of adults think smoking manufactured cigarettes is more harmful than smoking hand-rolled cigarettes.

Protection from Tobacco Smoke

The Nonsmoker's Health Protection Act of 1992 authorizes the Minister of Health to issue regulations to designate no smoking areas in public and work places. The Ministry of Health adopted a "step wise" approach to gradually increasing smoke free places covered by law. The initial regulation banned smoking in the 'easy to implement' public places such as hospitals, schools, air conditioned work places, and so forth. Designated smoking areas were allowed in non-air conditioned public and work places.

Subsequent regulation gradually removed designated smoking areas nearly everywhere. The ban of smoking in air conditioned restaurants was started by banning smoking in 50% of the area in 1992. In 1997, the no smoking area was increased to 75%. When the regulation totally banned smoking in air conditioned restaurants in 2003, the regulation was well received by the public with good compliance.

Hotel lobbies and pubs and bars were included in the ministerial regulation in 2007. The implementation of the smoke free law relies mainly on public pressure to make the law "self enforcing," because law enforcers often do not view smoking violations as very important. This may contribute to the results of GATS showing that 3 in 10 Thai adults are exposed to second hand smoke in indoor workplaces, and 1 in 10 in restaurants. In general, compliance is better in metropolitan public places than in provincial ones.

In 2010, the latest ministerial regulation required all indoor public and work places and other open-air public places such as market places and open-air restaurants to also ban smoking. The only indoor designated smoking rooms are allowed in international airports. With this regulation, the intention was to make all public places and work places smoke free. However, enforcement remains a problem in many of the more contentious public places such as pubs and bars, open air markets and eating places.

As stressed in the Guidelines of Article 8 of the WHO FCTC, [4] educating the public about the dangers of second hand smoke is crucial in supporting better compliance of smoke free law. GATS shows that 93.1% of Thai smokers and 95.5 % of nonsmokers agree that second-hand smoke causes serious health effects to nonsmokers.

Tax Policy

In 1993, the Thai cabinet adopted a policy to increase tax regularly with changes for inflation. By 2009, there have been nine cigarette tax increases, resulting in the retail price of the most popular cigarette brand rising from 15 to 58 Baht. The total annual sales volume decreased slightly in the same period. The annual cigarette excise tax collected rose from 15,000 million Baht in 1993 to 53,000 million Baht in 2010. The tax is now 69% of the retail price.

Superficially, it may appear that Thailand has a good tax policy in tobacco control. But the "ad valorem only" excise tax structure allowed the tobacco companies to introduce cheaper brand products in response to tax increases as well as engaging in under reporting their products' prices for tax valuation. The Ministry of Finance is in the process of changing the excise tax structure from "ad valorem only" to a retail price based calculation and a combined ad valorem and specific tax to overcome tobacco company tactics.

Another weak point in Thailand's tobacco tax system is the very low tax on roll your own cigarettes. With increasing cigarette excise taxes and prices, more and more smokers switch to cheaper hand rolled cigarettes. The Excise Department plans to levy higher taxes on roll your own cigarettes, but politicians are reluctant to act due to concerns about their popularity among poor smokers.

Tobacco and Alcohol Taxes for Health Promotion

By 1995, tobacco control was well established in Thailand with two comprehensive tobacco control laws, one in product control and one in smoke-free areas and a regular tax increase policy. The problem faced by the MOH at that time was in getting more budget to support tobacco control activities. Requests for more budgets through conventional channels were unsuccessful. There were also a handful of civil society and NGOs working on tobacco control due to a lack of government funding. This lack of funding led to research, advocacy and lobbying for the use of tobacco and alcohol taxes for tobacco and alcohol control, as well as for health promotion in general.

The argument presented to the Ministry of Finance and the Government was framed as an economic problem rather than as a purely health concern. The financial burden of treating diseases caused by tobacco and alcohol use, as well as from traffic accident injury were estimated and presented. Evidence was presented that a small investment in health promotion could cut the financial burden for treatment of non-communicable diseases. Most importantly, the proposed health promotion bill required the tobacco and alcohol companies to pay for the funding of health promotion since these two products are major causes of poor health in Thailand. The cabinet supported this idea and the parliament enacted it into law in 2001. [6] The two main features of the Health Promotion Fund Act of 2001 were the setting up of an "autonomous" health promotion agency and the requirement that the tobacco and alcohol companies would pay an "extra" 2% more whenever they paid "excise" taxes to the Excise Department. [7]

The autonomy of the Thailand Health Promotion Office, or ThaiHealth, enabled the office to be able to function effectively outside of the bureaucratic system using a funding by merit policy and its own fund administration. It also made the office less subject to political interference, abuse and the diversion or misuse of the funds. In 2008, the 94 million US dollar ThaiHealth budget was equivalent to 1.07% of the total Thai government health budget of 8,780 million US dollars. This underlines the importance of ThaiHealth in supporting health promotion in Thailand's national health system, especially in light of the increasing burden of disease caused by lifestyle or noncommunicable diseases. [8]

In 2010, the 2% extra excise tax from tobacco and alcohol that went into ThaiHealth coffers amounted to 105 million US dollars. This was used to fund 13 different programs, including tobacco, alcohol, nutrition, physical exercise, traffic accident prevention and other health promotion activities. The projects supported by ThaiHealth are "new work" or "new activity" which previously had been mainly supported by small overseas aid or grants in the form of pilot projects or "seed" money. [Table 1] shows the amount of budget ThaiHealth appropriated to fund various program areas in 2010.
Table 1: ThaiHealth's funding for major programs in millions of US dollars, 2010

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The ThaiHealth model has been widely regarded as a national innovative financing mechanism for health, both for tobacco control as well as prevention and control of non-communicable diseases, which are the major diseases in most countries.

The Indispensable Role of Civil Society

From Thailand's experiences, suffice it to say that without a strong civil society movement, Thailand would not have achieved what it has achieved in tobacco control today. The NGO focal point for tobacco control was formed in 1986 and has since remained active in its role as a pressure group to advocate and lobby for tobacco control. It assists Ministry of Health officials technically in the formulation of policy, in the preparation of draft regulations, legislation and with implementation.

It works continuously to generate public support for tobacco control policies by concentrating on public education about the health hazards of tobacco use and promoting non-smoking values. As a result, tobacco control policies become popular public policy and this make it easier for government to respond to tobacco control initiatives proposed by health advocates. The strong antismoking movement also deters politicians from identifying and associating with, or fighting for tobacco companies, at least openly.




   Much has been achieved, much more remains to be done Top


Although Thailand has made substantial progress in tobacco control, a WHO joint capacity assessment report on Thailand's tobacco control in 2008 revealed many weak points that need to be addressed. For example, the assessment found weak infrastructure for tobacco control at the provincial level, a low priority for cessation services, ineffective and inefficient tax administration, weak enforcement of smoke-free laws, and inadequate funding for tobacco control programs. Many recommendations provided by the assessment are only slowly being addressed. [9]


   What lessons have been learnt Top


In reflecting on the evolution of Thailand's tobacco control movement, several important points must be made: Most politicians as well as government officials do not consider tobacco control a priority Tobacco control is a long-term battle, due to the industry's marketing tactics and activities against tobacco control, and the addictiveness of tobacco products. The tobacco industry not only opposes tobacco control policy and legal initiatives, it also exploits legal loopholes and violates legal provisions, especially if enforcement is weak. Civil society and NGOs are indispensible; they need to pressure the government to act as well as serve as tobacco industry watch dogs. Civil society and NGOs need to denormalize smoking and the tobacco industry; the more they are denormalized, the easier it is to advance tobacco control policies. An adequate funding source is necessary in the implementation of various tobacco control interventions. A very logical source of funding is to use a fraction of tobacco taxes to fund tobacco control and/or health promotion. The WHO Framework Convention on Tobacco Control (WHO FCTC) and its guidelines are useful tools for civil society to advocate and pressure the government to fulfill its obligations under the treaty.

 
   References Top

1.WHO. Regional office for South East Asia. Global Adult Tobacco Survey: Thailand Country Report 2009. New Delhi, India, 2009.  Back to cited text no. 1
    
2.National Statistics Office. National Health and Welfare Survey. Bangkok, Thailand, 1991.  Back to cited text no. 2
    
3.National Statistics Office. Survey of Smoking and Drinking Behavior of the Population. Bangkok: Office of the Prime Minister, 2007.  Back to cited text no. 3
    
4.World Health Organization. WHO Framework Convention on Tobacco Control: Guidelines for implementation Article 5.3; Article 8; Article 11; Article 13. Geneva, 2009.  Back to cited text no. 4
    
5.Health Systems Research Institute of Thailand. Thailand's Tobacco Control Laws: Tobacco Product Control Act, 1992.  Back to cited text no. 5
    
6.Siwaraksa P. The Birth of the Thai Health Fund, Second Edition. Bangkok: Thai Health Promotion Foundation, 2003.  Back to cited text no. 6
    
7.Thai Health Promotion Foundation. Health Promotion Foundation Act, B.E. 2544 (2001).  Back to cited text no. 7
    
8.Thai Health Promotion Foundation. Health Promotion Foundation Act, Bangkok, 2001.  Back to cited text no. 8
    
9.Tangcharoensathien V. Unpublished data. Bangkok: International Health Policy Program, 2011.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]


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