Smoking and Tobacco Consumption in the Philippines

In 2009, the Department of Health (DOH) launched Unang Yakap, a newborn care campaign. "Yakap" is the Filipino term for embrace or hug, a nurturing motion that people do towards someone who is loved or who is in distress. Figuratively, "yakap" also means protecting something valuable like spirituality, social activism, education, the environment, or other interests that bring a positive influence or offer benefits to oneself, to others, or to society as a whole.

Though health (or kalusugan in Filipino) is a basic human need that should be embraced, not everyone takes good care of it. Not all Filipinos see their "kalusugan" as worthy of a "yakap". Such disregard for health often leads to poor healthy choices and behaviors like smoking and addiction to tobacco use. It is the same disregard that results in non-communicable illnesses that could have been prevented with appropriate information on healthy lifestyles and sound public health care policies that provide accessible, affordable, and efficient services and programs.

When the health of Filipinos is at stake, their "kinabukasan" or future is equally compromised, and so is the future of the Philippines in general.

Commitment to Public Health Care: The WHO and The Philippines

The World Health Organization (WHO) defines health as "a state of complete physical and social well being, and not merely the absence of disease or infirmity." As a key unit of the United Nations (UN), it assists member states by providing good health policies, standards, and protocols. This also includes helping governments achieve Millennium Development Goals (MDGs), particularly those that focus on "the continuum of care from pregnancy through to adolescence". It likewise supports other UN conventions that deal with gender discrimination and child's rights protection, and prescribes the institutionalization of "regulatory, economic, educational, organization-based, and community-based programs" that support healthy lifestyles and safe environments.

Among many global health problems, the WHO seeks to address the wide-ranging impact of tobacco consumption, including its effect on maternal, neonatal, infant, child, and adolescent health. Through the efforts of its Tobacco Free Initiative (TFA), more than 160 countries, including the Philippines, signed the Framework Convention on Tobacco Control (FCTC) in 2003. The FCTC limits the promotion, marketing, and smuggling of tobacco and tobacco products. Using them, as WHO Director-General Dr. Margaret Chan Fung Fu-chun says, "...is a risk factor for six of the eight leading causes of death in the world." Unless forestalled by effective smoking cessation measures, the WHO warns that current annual tobacco-related deaths of over five million could figure around 10 million in succeeding decades. It further notes that many of these deaths are likely to happen in developing countries where "smokers spend disproportionate sums of money relative to their incomes that could otherwise be spent on food, healthcare, and other necessities" (Tobacco Atlas 2009).

Indeed, the Philippines is not immune from tobacco-related diseases (e.g., lung and oral cavity cancers, hypertension, tuberculosis, etc.), causing about 35,000 Filipinos to die yearly (Panesa 2011). The Framework Convention on Tobacco Control Alliance Philippines (FCAP) reveals that the country "has the second highest number of smokers" in Southeast Asia, with smokers composing "Over a third of the country's 90 million population" (Santos 2010).

As a party to a number of WHO conventions and as stipulated in the Philippine Constitution, having good health then is a fundamental right of every Filipino. The government bears the responsibility to pass and enforce laws meant to deliver good health services and programs, especially for vulnerable groups (i.e., women, infants, children, and the youth) and marginalized communities. With tobacco as one of the preventable causes of health ailments, the country needs to strengthen its drive to curb smoking and improve the state of maternal and child health in the process.

Smoking and Public Health in The Philippines: Current Conditions, Policy Measures, and Related Studies

The Philippines passed the Tobacco Regulation Act (RA 9211) in 2003. In line with this and WHO's FCTC, the DOH later launched the "No to Sigarilyo" (NoSi; No to Cigarette) sticker project in collaboration with the Land Transportation and Franchising Regulatory Board (LTFRB). This measure required public utility vehicles to display the stickers, reminding passengers of the law against smoking in public.

The DOH also piloted the Red Orchid Program to recognize localities, government offices, health centers, and public hospitals with effective anti-smoking initiatives by adopting WHO's MPOWER tobacco control strategies: (1) Monitor tobacco use and prevention policies; (2) Protect people from tobacco smoke; (3) Offer help to quit tobacco use; (4) Warn against the dangers of tobacco; (5) Enforce bans on tobacco advertising; and (6) Raise taxes on tobacco. Awardees receive a grant of Php 100,000 to purchase drugs and medicines and are cited as "Best Practices" in the country's National Tobacco Control Program. Prior to this campaign, the government funded the Lung Cancer Control Program (LCCP) that supported anti-tobacco legislative efforts and used "Yosi Kadiri" (Smoking Sucks) and "'No Sa 'Yo" (It Isn't Cool to Smoke) campaigns.

Smoking and The Filipino - Young and Old, Men and Women

However, in spite of these efforts, the Global Youth Tobacco Survey (GYTS) show that "smoking prevalence among Filipino youth had jumped from 15 percent in 2003 to 21.6 percent in 2007." FCAP deplores the ineffective execution of the law that "sets both the guidelines for and regulation of the packaging, sale, distribution and advertisements of tobacco products" (Chapin 2009).

Moreover, based on the 2005-2006 Tobacco and Poverty Study in the Philippines, around 250 Filipinos everyday or 90,000 annually die due to smoking. Many of whom suffer from "cardiovascular, pulmonary, metabolic diseases, and cancers, especially lung cancers" (Chua 2009). Furthermore, according to the 2009 Global Adult Tobacco Survey (GATS), there are 17 million Filipino smokers aged 15 years old and over, as well as about 23 million inhale cigarette smoke at home everyday. Out of this population, men comprise 47.7 % (14.6 million), while 9% (2.8 million) are women. Many consume manufactured cigarettes and 80% of current nicotine addicts smoke on a daily basis.

The WHO reveals that Filipina smokers have reached 33%. The Philippine League of Government and Private Midwives, Inc. (PLGPMI) notes that the country has claimed the 16th spot in the list of Top Female Smoking Population in the World for 2009. The PLGPMI laments how tobacco firms lure women through "false images of vitality, slimness, emancipation, sophistication, and sexual allure. But in reality, smoking causes reproductive damage, disease and death..." Women smokers or recipients of second-hand smoke (synonymous with passive/involuntary smoking, environmental tobacco smoke (ETS), and environmental smoke pollution or ESP) often experience fertility problems, high-risk pregnancies, and increase their chances of having: "babies born prematurely, babies born too small, babies who die before they can be born at all" and "may cause a reduction in breast milk" (Penner 2010, American Cancer Society 2010, Woolston 2009, WHO 2010).

In addition, the Health Justice Philippines (HJP)and the Department of Social Welfare and Development (DSWD) note that secondhand smoke "is a form of violence against women" and that "smoking is the least explored among other forms of violence against women" (Balane 2008). FCAP opines that not wanting to fight with their smoking partners is what drives Filipino women to tolerate them. In another light, a study in the United States identifies childhood abuse "as a stressor that increases a woman's risk for smoking" among college students (Figueroa-Moseley, Abramson, and Williams 2010).

According to the International Pediatric Association or IPA (2010), "Tobacco use is a pediatric disease." FCAP avers that "The younger a child starts to smoke, the greater the chances of becoming a regular smoker." The IPA notes "... a low awareness of the importance of integrating tobacco control measures in child and adolescent health programmes and services among health professionals in general." It further views that "Child health and tobacco control is a strategic entry point for building capacity within the health sector." Health practitioners then have an essential role in helping individuals quit smoking successfully, as well as in guiding "communities adopt policies that promote smoke-free environments, and help families ensure that children are protected from second-hand smoke."

The WHO approximates that 250 million children worldwide could die because of tobacco use. The 2007 GYTS reveals that the Philippines has one of the highest figures of young smokers in Asia. Around 30% live in cities and over 70% aged 13-15 years old "use tobacco products, smoke cigarettes, chew tobacco and use 'shisha' (a water pipe for smoking)..." Aside from this and ETS, children and adolescents can also get sick of third-hand smoke or "the residue left in a room after someone smokes, which often sticks to furniture and clothes. Infants and young children who play with items that have been exposed to cigarette smoke can eventually develop asthma and other smoking-related diseases" (Santos 2010).

The Role of Cigarette Manufacturing Companies and the Food and Drug Administration

One possible factor for these alarming rate of young smokers was the concerted effort of major cigarette manufacturing firms (i.e., Mighty Corporation and Fortune Tobacco) to block the implementation of DOH Administrative Order (AO) 2010-0013 in adherence to FCTC guidelines. Said AO requires these companies to avoid using "misleading words on cigarette packs like 'mild', 'light', 'ultra-light', and 'low tar'. It also pushes for graphic warnings in lieu of textual messages to discourage children and young people from smoking. A Regional Trial Court (RTC) issued an injunction order in favor of the tobacco companies. Consequently, a group of former DOH secretaries (i.e., Drs. Esperanza Cabral, Francisco Duque III, Alberto Romualdez Jr., Jaime Galvez-Tan, and Alfredo Bengzon) have asked the Supreme Court to decide on the case (Panesa 2011).

A recent development however shows that the newly approved Implementing Rules and Regulations (IRR) of the Food and Drug Administration (FDA) have given the DOH more "power to regulate tobacco products in the country, among other supplementary mandates" (Uy 2011). The IRR allows the FDA to "examine the nicotine levels or any substance in cigarettes", as well as to "reinforce its partnership with other agencies, including the US-FDA to regulate tobacco use." It also provides the FDA the power to: (1) confiscate non-compliant items without the need for a court order, and (2) "... hold in contempt any person who ignores orders and writs issued by the agency." This then involves the strict implementation of AO 2010-0013 (Uy 2011).

The International Tobacco Control (ITC) Policy Evaluation Project affirms that the use of pictorial warnings on how smoking affects the body have a considerable deterrent effect on young smokers, including children. These images can inspire them to consider quitting, as well as reinforce the decision of others not to smoke. Moreover, these help people to protect themselves from ETS.

Challenges to Smoking Cessation and Improving Public Health in the Philippines

Though the Philippines has achieved some legislative and institutional success in support of WHO's FCTC and MPOWER policy strategies against smoking and tobacco use, the Tobacco Atlas - a joint venture of the World Lung Foundation (WLF) and the American Cancer Society (ACS) - identifies that "the lack of standardized data and inadequate communication networks, tobacco-control research capacity, and human and financial resources" hinders developing countries to fully participate in international tobacco control research initiatives.

The Philippine Legislators' Committee on Population and Development (PLCPD) reports that budgetary allocation for health has been dismal at 1.6% or only 3% of the country's GNP (gross national product) compared to WHO's 5% GNP standard (Tulali, 2010). Using the results of the 2006 Tobacco and Poverty Survey, the HJP and the Southeast Asia Tobacco Control Alliance (SEATCA) note the high health care costs and productivity losses related to tobacco consumption at 148.47 to 314.38 billion pesos compared to over than $6 billion in 2003. This echoes the WHO's position:

"The economic costs of tobacco use are equally devastating. In addition to the high public health costs of treating tobacco-caused diseases, tobacco kills people at the height of their productivity, depriving families of breadwinners and nations of a healthy workforce. Tobacco users are also less productive while they are alive due to increased sickness. A 1994 report estimated that the use of tobacco resulted in an annual global net loss of $200 billion, a third of this loss being in developing countries."

Another economic consideration in the tobacco-free programs is the impact these will have on the tobacco industry whose production reached Php 4.7 billion in 2010. Moreover, as the National Tobacco Administration (NTA) reports, the industry contributes "... an average of P30 billion annually to the national coffers from the excise tax payments of cigarette manufacturers." The NTA is a regulatory body under the Department of Agriculture (DA) which is tasked to advance and protect those whose livelihoods depend on the tobacco industry.

Tobacco and the Philippine Economy - Government Efforts and Increased Taxes

Tobacco has played a crucial role in Philippine history and in the country's economic development. Plantations of this crop can be found "in 27 provinces, covering approximately 40,297 hectares" (NTA 2008). Presently, the industry benefits almost two million Filipinos. This includes over 62,000 tobacco farmers and their families, as well as technicians and workers in cure barn, trading center re-drying plants, and cigarette factories.

The Philippine government, through the DA-NTA, invested in the establishment of a "Quality Assurance Laboratory". The facility has "state-of-the-art analytical equipment, capable of detecting the presence and level of toxins and carcinogenic substances on tobacco leaf and tobacco products, which are the burning issues oft-repeatedly raised by some government and non-government health advocates."

Edgardo Zaragoza, current NTA administrator, conducted a series of dialogues with tobacco farmers to "advocate the massive production of high-quality tobacco" as the world market continues to demand for the product "despite the presence of smear campaign against tobacco smoking by various health groups..." He is committed "to earn more income for our government coffers and help our farmers to raise their standard of living." This goal is aligned with President Benigno Aquino III's vision of improving the lives of Filipinos. Thus, it opposes increasing cigarette taxes, for it will raise cigarette prices and negatively affect the economic conditions of tobacco industry workers and their families.

Likewise, the International Tax and Investment Center (ITIC) claims that such tax hike would only be counterproductive, for it will "encourage consumers to switch from legitimate - meaning tax paid - sources to contraband tobacco... higher taxes would undermine the quality of products entering the market, encourage a culture of tax evasion and crime, deter investment in developing markets by international companies and weaken the tax base."

However, Frank J. Chaloupka (2009), an economics professor, notes that though raising tobacco taxes could result in smuggling, pricey cigarettes can "induce current users to try to quit, keep former users from restarting, prevent potential users from starting, reduce consumption among those who continue to use, and lead to other changes in tobacco use behavior." Also, with the shift towards a less moneyed market targets, the price increase will deter less-educated and/or lower-income smokers from sustaining such unhealthy lifestyle. Raising tobacco tax then becomes an effective anti-smoking policy.

In response to tax increases and other efforts to reduce tobacco use, major industry players like Phillip Morris-Fortune Tobacco, whose "Marlboro" brand is the top-selling cigarette product in the Philippines, resort to "predatory marketing" by aggressively promoting ads that cater to women and the youth. The cheap price of single cigarette stick and its availability in many neighborhood sari-sari stores or retail/convenience shops have also contributed in the increased number of tobacco users among youngsters and women. Add to this the exposure to more media-produced images of famous personalities smoking in movies, music videos, reality shows, and teleseryes (TV series).

An Alternative Approach to Curb Smoking and Tobacco Use

The PLGPMI strongly advises the adoption of "new and creative approaches" to lessen, if not eradicate, the "the inequity of health services and the maldistribution of health workers in the provinces..." It likewise recommends that the government "build on the strengths and capacities of the existing workforce by developing the needed competencies to effectively provide services in hospitals and even in remote communities." PLGPMI further asserts that "The people, too, have a right and duty to participate individually and collectively in the planning and implementation of their health care. The public would not be given false hopes of free health care for all but instead will inform them that the poor will be taken care of by the government while those who can pay must do so according to their financial capacity."

Undoubtedly, pursuing an effective drive towards smoking-free, healthy living to address these issues involves a comprehensive approach that would allow a strategic partnership between health advocates and agencies and those who benefit from the tobacco industry, as well as the cooperation of the academic and research institutions, media companies, civil society organizations (CSOs), and community-based groups. The NTA has already started exploring alternatives to tobacco use. These include the production of: (1) tobacco dust as molluscicide cum fertilizer for fishponds; (2) tobacco hand-made paper; (3) tobacco "virgin" pulp for the manufacture of various types of paper, packaging materials and specialty papers, among others; (4)tobacco extracts as organic pesticides for fruits (mango), vegetables, and ornamentals; and (5) ethanol from tobacco stalks.

Further support to develop these other options could definitely serve as a means to lessen, if not eliminate, the clashing goals and interests. After all, the tobacco industry and the Philippine economy as a whole would also suffer if its workers' productivity and those of its consumers get afflicted with tobacco-related diseases caused by smoking.

References

American Cancer Society. 2010. "Secondhand Smoke". http://www.cancer.org/cancer/cancercauses/tobaccocancer/secondhand-smoke. Accessed 18 March 2011.

Balane, Lilita. 2008. "Law Allows Women to Force Partners to Quit Smoking". Newsbreak. December 5. http://www.abs-cbnnews.com/lifestyle/12/05/08/law-allows-women-force-partners-quit-smoking. Accessed 19 March 2011.

Chapin, John. 2009. "Philippines Effort to Cut Smoking Goes up in Smoke". The Cutting Edge News. May 11. http://www.thecuttingedgenews.com/index.php?article=11315&pageid=24&pagename=Society. Accessed 16 March 2011.

Chua, Philip S.2009. "Smoking Kills 250 Daily". Cebu Daily News. December 7. http://globalnation.inquirer.net/cebudailynews/opinion/view/20091207-240632/Smoking-kills-250-daily. Accessed 18 March 2011.

Department of Health. 2007. Administrative Order 2007-0004: National Tobacco Prevention and Control Program. January 15. http://www.doh.gov.ph/files/ao2007-0004.pdf. Accessed 16 March 2011.

Figueroa-Moseley, Colmar De Von; Abramson, Jill Marise; and Williams, Geoffery C. 2010. "College Women: History of Childhood Abuse and Its Relationship to Smoking". Violence Against Women. November 22. Vol. 16: 1242-1251. http://vaw.sagepub.com/content/16/11/1242.short. 20 March 2011.

Llaguno, Frankie. 2010. "Filipino Girls Among Biggest Smokers in the World - WHO". Newsbreak. May 28. http://www.abs-cbnnews.com/-depth/05/28/10/filipino-girls-among-biggest-smokers-world-%E2%80%94who. Accessed 19 March 2011.

Panesa, Edmer. 2011. "SC Asked to Allow Use of Anti-Smoking Warnings". Manila Bulletin. January 17. http://www.mb.com.ph/articles/299045/sc-asked-allow-use-antismoking-warnings. 18 March 2011.

Penner, Steve. 2010. "The Truth about Dating: Run away from that Smoker". February 26. http://www.seacoastonline.com/articles/20100226-ENTERTAIN-2260306. Accessed 19 March 2011.

Philippine League of Government and Private Midwives, Inc. (PLGPMI). 2011. Statement released for its 12th General Assembly in April 2011. http://www.doh.gov.ph/files/dc2010-0302.pdf. 18 March 2011.

Santos, Kara. 2010. "Young Lives Up in Smoke". Inter Press Service News. IPS News Agency. February 15. http://www.ipsnews.net/news.asp?idnews=50320. Accessed 18 March 2011.

Tulali, Carlos O. 2010. "Philippine Policies on Maternal, Newborn, and Child Health and Nutrition: Towards Achieving MDGs 4 and 5". In People Count PLCPD Policy Brief. Philippine Legislators' Committee on Population and Development (PLCPD) Foundation, Inc. with support from the United Nations Population Fund (UNFPA).

Uy, Jocelyn R. 2011. "Tighter regulation of tobacco, cigarette manufacturing approved". Philippine Daily Inquirer. March 16. http://newsinfo.inquirer.net/breakingnews/nation/view/20110316-325681/Tighter-regulation-of-tobacco-cigarette-manufacturing-approved. 20 March 2011.

Woolston, Chris. 2009. "How Smoking During Pregnancy Affects You and Your Baby". Reviewed by the Baby Center Medical Advisory Board. http://www.babycenter.com/0_how-smoking-during-pregnancy-affects-you-and-your-baby_1405720.bc. Accessed 18 March 2011.

WHO Western Pacific Region. 2011. "Governments Vow to Step Up Fight Against Lifestyle Diseases". March 18. http://www.wpro.who.int/media_centre/press_releases/pr20110318.htm. Accessed 16 March 2011.

________________________. 2010. "Fact Sheet for World No Tobacco Day: Empower and Protect Women from Tobacco Marketing and Smoke." May 27. http://www.wpro.who.int/media_centre/fact_sheets/factsheet_20100527.htm. Accessed 16 March 2011.

________________________. 2009. "Tobacco Smoking Among Women in the Western Pacific Region. December 9. http://www.wpro.who.int/media_centre/fact_sheets/fs_20091209_womensmokers.htm. Accessed 16 March 2011.


Written by Leann Zarah (leannzarah@gmail.com)

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