Socioeconomic Differences in the Effectiveness of the Removal of “Light” and “Mild” Descriptors on Cigarette Packs: Findings from the International Tobacco Control (ITC) Thailand Survey. University of Nebraska Medical Center Mohammad SiahpushUniversity of Nebraska Medical Center, USA Ron Borland The Cancer Council Victoria, Australia Geoffrey T. FongUniversity of Waterloo, Canada Tara Elton-MarshallPropel Center for Population Impact, Canada Hua-Hie Yong The Cancer Council Victoria, Australia Charamporn HolumyongThapra, Bangkokyai, Bangkok, Thailand Jessica L. Reid University of Waterloo, Canada

2 Introduction and Aim While there is a growing literature on the effect of tobacco control policies on smoking- related behaviors, beliefs, and attitudes, less attention has been given to how this effect varies by socioeconomic position. Article 11 of the World Health Organization’s (WHO) Framework Convention on Tobacco Control (FCTC) calls for laws that ensure that tobacco packaging and labeling do not promote tobacco products by any means, such as the use of “light” and “mild” descriptors, that create a false impression of their health hazards. In March 2007, Thailand implemented the policy of banning the use of “light” and “mild” descriptors on cigarette packs. The aim of this study was to assess changes in beliefs about “Light” and “Mild” cigarettes in Thailand following their removal in 2007 and whether changes in beliefs differed across levels of income and education.

3 Methods Data: The data came from waves 2 ( 2006 ), 3 ( 2008 ), and 4 ( 2009 ) of the International Tobacco Control (ITC) Thailand Survey of adult smokers, which is part of the ITC Southeast Asia (ITC-SEA) Survey with a parallel survey in Malaysia. ITC Thailand is a nationally representative prospective cohort study designed to evaluate the psychosocial and behavioral impact of key national-level tobacco control policies. Measurement: Two questionnaire items were used to measure smokers’ beliefs about “light” cigarettes: “Light cigarettes are less harmful than regular cigarettes” and “Light cigarettes are smoother on your throat and chest than regular cigarettes”. Respondent were asked to indicate their agreement with each statement on a five-point scale ranging from ( 1 ) “strongly disagree” to ( 5 ) “strongly agree”. These items have been used in previous research on beliefs about “light” cigarettes [1-4]. Baseline income and education were used as indicators of socioeconomic position. Annual household income was categorized into three groups of low ( 36,001 and baht). Similarly, education was categorized into three groups of low (no schooling and elementary), medium (lower and upper secondary), and high (diploma, bachelors degree, and higher).

4 Methods (contd.) Statistical analysis: Normal regression, with generalize estimating equation and robust variance, was employed to estimate the association of income, education, survey year, and control variables with beliefs about “light” cigarettes. In order to examine whether there was a socioeconomic difference in the effect of the policy, we assessed the interaction of income or education with survey year, all treated as categorical variables. Several time-varying control variables were considered in the multiple regression analyses: smoking status, number of cigarettes smoked per day, quit attempt in the past six months, use of factory-made cigarettes versus roll-your-own (RYO) cigarettes versus a mix of both. Several time-invariant control variables were also considered: age, sex, residing in urban versus rural regions, residing in Bangkok versus other cities or towns, and wave of recruitment in the ITC Thailand. The analysis included data from 2,352 respondents, of whom 704 contributed data to one wave, 766 to two waves, and 882 to three waves. There were 1,468, 1,728, and 1,686 respondents in waves 2, 3, and 4, respectively. A total of 4,882 person-wave observations were included in the regression models.

Results Figures 1 and 2 show the trend from 2006 to 2009 in the mean of agreement with the “less harmful” statement by levels of income and education, respectively. In all survey years, higher income and higher education were associated with a stronger belief that “light” cigarettes are less harmful. The mean of agreement in all groups declined after the introduction of the policy. Multiple regression analysis of the “less harmful” belief showed that there was an interaction between income and survey year (p = ), and education and survey year (p = ). The decline through the period of the study was much greater in the low income than the high income group. Similarly, there was a much greater decline in the low education than the high education group in This pattern of results indicated a decreasing trend in socioeconomic disparities in belief in harmfulness of “light” cigarettes. Results for the belief that “light” cigarettes are smoother also showed that after the introduction of the policy, there was a decline in this belief. Multivariate analyses showed no evidence that the decline varied by income or education. 5

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8 Discussion We found that, following the implementation of the policy, there was a decline in the belief that “light” cigarettes are healthier than regular cigarettes, and that this decline was sharper among lower socioeconomic groups. While the belief that “light” cigarettes are smoother than regular cigarettes also declined, there was no evidence of a socioeconomic difference in the rate of decline. Our findings suggest that information on packs may be a more important source of smoking- related beliefs in lower socioeconomic smokers. This could be because they are less likely to have information from other sources. As far as we know, there were no ancillary health education campaigns to reinforce the fact that “light” cigarettes are not less harmful. It is possible that the larger effects among lower socioeconomic groups is because they simply assumed that a descriptor such as “light” or “mild” inferred reduced harm, and with its removal, this assumption was no longer as plausible.

9 Discussion (Contd.) Given the socioeconomic disparities in smoking behavior and smoking-related beliefs [5-10], identifying or developing policies that can reduced these disparities should be a priority in tobacco control efforts. Removing “light” and “mild” brand descriptors on cigarette packs should be viewed not only as a means to address the problem of smokers’ incorrect beliefs about “light” or “mild” cigarettes, but as a factor that can potentially reduce smoking disparities in smoking-related misconceptions.

10 1.Borland, R.; Fong, G.T.; Yong, H-H; Cummings, K.M.; Hammond, D.; King, B.; Siahpush, M.; McNeill, A.; Hastings, G.; O'Connor, R.J.; Elton- Marshall, T.; Zanna, M.P. What happened to smokers' beliefs about light cigarettes when "light/mild" brand descriptors were banned in the UK? Findings from the international tobacco control (ITC) four country survey. Tobacco Control 2008, 17, King, B.; Yong, H-H.; Borland, R.; Omar, M.; Ahmad, A.A.; Sirirassamee, B.; Hamann, S.; O'Connor, R.J.; Bansal-Travers, M.; Elton-Marshall, T.; Lee, W.B.; Hammond, D.; Thrasher, J. Malaysian and Thai smokers' beliefs about the harmfulness of 'light' and menthol cigarettes. Tobacco Control 2010, 19, Borland, R.; Yong, H-H.; King, B.; Cummings, K.M.; Fong, G.T.; Elton-Marshall, T.; Hammond, D.; McNeill, A. Use of and beliefs about light cigarettes in four countries: Findings from the international tobacco control policy evaluation survey. Nicotine & Tobacco Research 2004, 6 (Suppl 3), S Elton-Marshall, T.; Fong, G.T.; Zanna, M.P.; Jiang, Y.; Hammond, D.; O'Connor, R.J.; Yong, H-H.; Li, L.; King, B.; Li, Q.; Borland, R.; Cummings, K.M.; Driezen, P. Beliefs about the relative harm of "light" and "low tar" cigarettes: Findings from the international tobacco control (ITC) china survey. Tobacco Control 2010, 19 (Suppl 2), i Siahpush, M.; McNeill, A.; Hammond, D.; Fong, G. Socioeconomic and country variations in knowledge of health risks of tobacco smoking and toxic constituents of smoke: Results from the 2002 international tobacco control policy evaluation survey. Tobacco Control 2006, 15(Suppl 3), iii65-iii70. 6.Borland, R.; Yong, H-H.; Balmford, J.; Fong, G.T.; Zanna, M.P.; Hastings, G. Do risk-minimizing beliefs about smoking inhibit quitting? Findings from the international tobacco control (ITC) four-country survey. Preventive Medicine 2009, 49, Siahpush, M.; Borland, R.; Yong, H-H.; Kin, F.; Sirirassamee, B. Socio-economic variations in tobacco consumption, intention to quit and self- efficacy to quit among male smokers in Thailand and Malaysia: Results from the international tobacco control-South-East Asia (ITC-SEA) survey. Addiction 2008, 103, Siahpush, M.; McNeill, A.; Borland, R.; Fong, G.T. Socioeconomic variations in nicotine dependence, self-efficacy and intention to quit across four countries: Findings from the international tobacco control policy evaluation survey. Tobacco Control 2006, 15 (Suppl 3), iii71-iii75. 9.Reid, J.L.; Hammond, D.; Boudreau, C.; Fong, G.T.; Siahpush, M.; ITC Collaboration. Socioeconomic disparities in quit intentions, quit attempts, and smoking abstinence among smokers in four western countries: Findings from the international tobacco control four country survey. Nicotine & Tobacco Research 2010, 12 (Suppl), S Siahpush, M.; Yong, H-H.; Borland, R.; Reid, J.L. Socioeconomic position and abrupt versus gradual method of quitting smoking: Findings from the international tobacco control four-country survey. Nicotine & Tobacco Research 2010, 12 (Suppl), S58-63 References

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