The Tobacco Pack Surveillance System: A Protocol for Assessing Health Warning Compliance, Design Features, and Appeals of Tobacco Packs Sold in Low- and Middle-Income Countries

Abstract

BackgroundTobacco remains the world’s leading preventable cause of death, with the majority of tobacco-caused deaths occurring in low- and middle-income countries. The first global health treaty, the Framework Convention on Tobacco Control (FCTC), outlines a set of policy initiatives that have been demonstrated as effective in reducing tobacco use. Article 11 of the FCTC focuses on using the tobacco package to communicate tobacco-caused harms; it also seeks to restrict the delivery of misleading information about the product on the pack.ObjectiveThe objective of this study was to establish a surveillance system for tobacco packs in the 14 low- and middle-income countries with the greatest number of smokers. The Tobacco Pack Surveillance System (TPackSS) monitors whether required health warnings on tobacco packages are being implemented as intended, and identifies pack designs and appeals that might violate or detract from the communication of harm-related information and undermine the impact of a country’s tobacco packaging laws. The protocol outlined is intended to be applicable or adaptable for surveillance efforts in other countries.MethodsTobacco packs were collected in 14 countries during 2013. The intention was, to the extent possible, to construct a census of “unique” pack presentations available for purchase in each country. The TPackSS team partnered with in-country field staff to implement a standardized protocol for acquiring packs from 36 diverse neighborhoods across three cities in each country. At the time of purchase, data on price and place of acquisition of each pack was recorded. The field staff, according to a standardized protocol, then photographed packs before they were shipped to the United States for coding and archiving.ResultsEach pack was coded for compliance with the country-specific health warning label laws, as well as for key design features of the pack and appeals of the branding elements. The coding protocols were developed based upon prior research, expert opinion, and communication theories. Each pack was coded by two independent coders, with consistency of personnel across the project. We routinely measured intercoder reliability, and only retained variables for which a good level of reliability was achieved. Variables where reliability was too low were not included in final analyses, and any inconsistencies in coding were resolved on a daily basis.ConclusionsAcross the 14 countries, the TPackSS team collected 3307 tobacco packs. We have established a publicly accessible, Internet archive of these packs that is intended for use by the tobacco control policy advocacy and research community.

Cigarette stick as valuable communicative real estate: a content analysis of cigarettes from 14 low-income and middle-income countries

“…We collected data in the 14 low-income and middle-income countries with the greatest number of smokers (Bangladesh, Brazil, China, Egypt, India, Indonesia, Mexico, Pakistan, Philippines, Russian Federation, Thailand, Turkey, Ukraine and Vietnam). In each country, we collaborated with a local agency to implement a common data collection protocol 12. Our sampling approach maximised the number and diversity of packs acquired in each country.…”

Compliance with Uruguay’s single presentation requirement

“…The field protocol for this pilot study was adapted from the Tobacco Pack Surveillance System (TPackSS) study. 9 The protocol involved purchasing one of each unique cigarette pack available at tobacco retailers in Montevideo, Uruguay. A pack was considered unique if it differed in at least one exterior pack feature, including stick count, size, brand name, colours or design elements.…”

The Use of Sports Imagery and Terminology on Cigarette Packs from Fourteen Countries

“…In each sample neighborhood, cigarette vendors were identified, and cigarette packs were purchased with the intention of collecting as many unique pack presentations as possible. Detailed sampling and data collection methods are outlined elsewhere (Smith et al, 2015).…”