Determining the extent and nature of illicit cigarette use in Malaysia involving pack collection and interview: Findings from the wave 4 ITC study Rahmat Awang, Maizurah Omar (Clearinghouse for Tobacco Control, USM, Penang) Ron Borland and Hua Yong (Cancer Vic, Melbourne) Geoffrey Fong, Mary Thompson, Anne CK Quah (University of Waterloo, Canada) Zarihah Zain (Malaysian Ministry of Health) Dato’ Azizah Idris (Malaysian Royal Custom) Effective Implementation of FCTC Policies Pre-Conference Workshop, 15th World Conference on Tobacco or Health, Singapore, 19 March 2012

Background Over the last 10 years, the Malaysian government has been increasing cigarette tax and currently the tax is about 56%. Since 2003, the Confederation of Malaysian Tobacco Manufacturers (CMTM) continuously lobbied the Malaysian Government They recently reported an upward trend from 14.4% in 2004 to the current (2010) 37% One out of three packets of cigarettes are smuggled To date, no evidence from other sources (apart from the industry) regarding this issue

Press released by CMTM? CMTM is an industry organization of Philip Morris International Affiliates in Malaysia, British American Tobacco (Malaysia) Berhad and JT International Berhad. The Star, 26 April 2011

What CMTM reported?

Main Aim of the Study To evaluate the extent of illicit cigarette trade in Malaysia. To provide independent and credible source of illicit cigarette trade data to the government To pilot the ITC methodology particularly telephone interview technique in addressing this issue.

SPECIFIC OBJECTIVES Do illicit products carry a tax stamp or security ink and do these labels follow the government’s specification? Do illicit products carry a health warning and prohibition to minors? Do illicit products carry the message “about 4000 chemical constituents of cigarette”? Are illicit products sold in the same location as legal products? Are illicit products more attractive compared to legal products? Why and among whom? Are illicit products cheaper than the legal products? What is the magnitude of the difference in average price between illicit and legal products? Do illicit products taste better than the legal products? Are illicit product easily accessible to the smokers? Who is more likely to buy illicit products, men or women, urban or rural residents? What are the locally existing illicit packages and their representative companies? Do our illicit cigarette findings different from industry findings?

METHODOLOGY Cross-sectional data of the ITC Wave 4 survey Conducted between July 2009 and December 2009 Multi-stage stratified cluster sampling technique Participants were interviewed through telephone Currently used cigarette pack were mailed. Total number of factory made cigarette smokers in the study: 1744 Total packs received were from 692 smokers Each collected pack undergone physical observations to identify whether they were genuine or illicit packages

CHECK LIST TO DETERMINE ILLICIT CIGARETTE PACK Absence of any of the following check list items was considered as illicit pack: 1. Graphic health warnings (40% covers front and 60% at the back) 2. Label: “Produk in mengandungi lebih 4,000 bahan kimia termasuk tar, nikotina dan karbon monoksida yang membahayakan kesihatan”. 3. Label: Warning against selling to minors. 4. Label: Info line number 5. Contain genuine security ink or tax stamp

Current Graphic Health Warning Labels

Duck to verify the security ink

Tax Stamps Fine line security Two types of tax stamp Alphanumeric and status tax stamps Yellow fluorescence by using UV light Custom logo Micro text

Characteristics of respondents who sent and not sent the packs Not Received Received State (N=1711) Sabah /Sarawak 74.5% 25.5% Kedah 48.5% 51.5% Penang 56.9% 43.1% Selangor 63.0% 37.0% Terengganu 53.4% 46.6% Johor 67.3% 32.7% Residential (N=1711) Urban 63.4% 36.6% Rural 62.4% 37.6% Education (N=1578) Primary 65.5% 34.5% Secondary 62.7% 37.3% Tertiary 59.5% 40.5% Age a35.01 (sd- 57.92) a32.08(sd-13.02)   weighted data. a mean, sd- standard deviation

Characteristics of respondents who sent and not sent the packs cont... Not Received Received Income (N=1479) Low 64.4% 35.6% Middle 59.3% 40.7% High 63.5% 36.5% Gender (N=1711) Male 63.1% 36.9% Race (N=1705) Malay 59.6% 40.4% Others 78.6% 21.4% Employment (N=1479) Professional 81.9% 18.1% Non-Professional 57.9% 42.1% Technical 61.5% 38.5% Unemployed 64.1% 35.9%   weighted data

Relationship between characteristics of respondents and pack sent or not sent Univariate P-value OR (95%CI) States n=1711 Sabah & Sarawak Ref *** Kedah 3.09 (1.95-4.91) Penang 2.23 (1.44-3.45) Selangor 1.72 (1.29-2.31) Terengganu 2.55 (1.86-3.50) Johor 1.42 (1.02-1.98) Residential Urban RefNS Rural 1.05 (0.85-1.29) Education n=1578 Primary Secondary 1.12 (0.74-1.69) Tertiary 1.28 (0.86-1.93) Reported OR and 95% CI were from multiple logistic regression. NS Not significant, *p<0.05, **p<0.01, ***p<0.001 n- number of respondents in univariate analysis.

Relationship between characteristics of respondents and packs sent or not sent cont... Univariate P-value OR (95%CI) Income (n=1429) Low Ref *** Middle 1.23 (0.98-1.55) High 1.04 (0.76-1.44) Age (n=1711)   T-TEST t(1684)=-1.35, p=0.176a Race (n=1705) Malay Others 0.40 (0.30-0.54) Employment (n=1479) Professional Non-Professional 3.24 (1.89-5.56) Technical 2.78 (1.57-4.93) Unemployed 2.49 (1.40-4.45) Compare to low income people, middle and high income respondents significantly more likely to send the packs. Reported OR and 95% CI were from multiple logistic regression. NS Not significant, *p<0.05, **p<0.01, ***p<0.001 Significant age*State interaction present (P<0.001). a p value independent sample T-Test. n-number of respondents in univariate analysis

Percentage of ILLICIT packs received (N=685)

Types of popular cigarettes packs identified as ILLICIT Brand Product (n=total pack collected) Companies % of total illicit cig (% illicit of total pack received from same pack) Dunhill (n=286) British American Tobacco 3.5 (0.7) Marlboro (n=37) Philip Morris 9.2 (32) Winston (n=75) Japan Tobacco International 13.5 (24) Gudang Garam (n=56) 36.8 (84) Total brands as illicit = 16

ILLICIT cigarette packages received based on check list

Characteristics of respondents who sent illicit or genuine packs State (n=685) Sabah /Sarawak 39.4% 60.6% Kedah 92.0% 8.0% Penang 90.0% 10.0% Selangor 84.6% 15.4% Terengganu 86.4% 13.6% Johor 92.2% 7.8% Residential (n=685) Urban 81.6% 18.4% Rural 79.0% 21.0% Education (n=651) Primary 82.9% 17.1% Secondary 78.3% 21.7% Tertiary 84.8% 15.2% Employment (n=613) Professional 88.2% 11.8% Non-Professional 80.3% 19.7% Technical 85.3% 14.7% Unemployed 78.7% 21.3% Illicit *weightage data

Characteristics of respondents who sent illicit or genuine packs (cont Gender (N=685) Male 80.9% 19.1% Age (N=679) Race (N=684) Malay 86.5% 13.5% Others 30.3% 69.7% Income (N=578) Low 76.3% 23.7% Middle 84.5% 15.5% High 89.3% 10.7% Reason for choosing particular brand   Taste (N=662) No 20.5% 24.1% Yes 79.5% 75.9% Price (N=664) 62.0% 34.6% 38.0% 65.4% Health (N=652) 80.8% 76.9% 19.2% 23.1% Illicit *weightage data

Relationship between characteristics of respondents and received ILLICIT or genuine packs Univariate P-value, OR (95%CI) States n=685 Sabah /Sarawak Ref *** Kedah 0.06 (0.02-0.17) Penang 0.08 (0.03-0.21) Selangor 0.12 (0.07-0.21) Terengganu 0.11 (0.06-0.19) Johor 0.06 (0.02-0.13) Residential Urban RefNS Rural 1.17 (0.78-1.75) Education n=651 Primary Secondary 1.35 (0.56-3.25) Tertiary 0.89 (0.37-2.13) Employment Professional Non-Profaessional 1.94 (0.42-8.85) Technical 1.35 (0.28-6.58) Unemployed 2.12 (0.44-10.27) Income n=578 Low Middle 0.58 (0.36-0.93) High 0.36 (0.16-0.81) Compare to sabah/sarawak significantly less likely contraband packs in other states. Weighted data. n- number of respondents in univariate analysis. Reported OR and 95% CI were from univariate & multiple logistic regression. NS Not significant, *p<0.05, **p<0.01, ***p<0.001

Relationship between characteristics of respondents and received ILLICIT or genuine packs Univariate P-value, OR (95%CI) Age n=679 T-Test T(679)=0.018, P=0.985a Race n=684 Malay Ref *** Others 14.54 (8.19-25.81) Reason for choosing particular brand Taste n= 662 No RefNS Yes 0.81 (0.50-1.31) Price n=664 Ref*** 3.07 (1.99-4.74) Health n=652 1.28 (0.78-2.11) Compare to Malays, other races odds 3.46 times more likely to use contraband packs. Odds of 6.39 times more likely to use illicit cigarette because of the price. Weighted data. n- number of respondents in univariate analysis. Reported OR and 95% CI were from univariate . NS Not significant, *p<0.05, **p<0.01, ***p<0.001. a p value independent sample T Test

Places where ILLICIT packs were bought (N=139)

Conclusions In our study, about 19% of Malaysian smokers use illicit cigarette All states documented illicit cigarette use but Sabah and Sarawak were among the highest user State, race and price are significantly associated with smoking illicit cigarette. Illicit cigarettes are easily accessible in convenience stores. . The ITC methodology using telephone interview and requesting pack once demonstrated its potential for measuring extent of illicit use cigarette in the country.

ACKNOWLEDGEMENT The ITC-SEA Project is supported by grants P50 CA111236 (Roswell Park Transdisciplinary Tobacco Use Research Center), R01 CA100362 from the National Cancer Institute of the United States, Canadian Institutes of Health Research (79551), Ontario Institute for Cancer Research, ThaiHealth Promotion Foundation, and the Malaysian Ministry of Health. We would also like to acknowledge the other members of the ITC Project team.

ITC Project Research Support ITC Project Research Organizations   ITC Project Research Support Core support provided by the U.S. National Cancer Institute to the Roswell Park TTURC (P01 CA138389) Additional major funding provided by the Canadian Institutes of Health Research ITC Project Research Organizations

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