Rahmat Awang Clearinghouse for Tobacco Control, Universiti Sains Malaysia, Penang Determining the extent and nature of illicit cigarette use in Malaysia involving pack collection and interview: Findings from the wave 4 and 5 ITC study Effective Implementation of FCTC Policies Pre-Conference Workshop, 15 th World Conference on Tobacco or Health, Singapore, 19 March 2012

Background Imposing taxes on tobacco is one of the most efficient and effective measures to reduce tobacco use: - it can reduce consumption significantly - increase government revenue Despite this, many governments are reluctant to raise taxes, due to concerns about smuggling and the possible impact on the poor. In Malaysia, the tobacco industry uses data showing increasing prevalence of smuggling and lobbied the government not to raise tax or to keep cigarette taxes low.

The Star, 26 April 2011 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.

What CMTM reported?

In last year (2011) national budget review, the Malaysian government did not raise tobacco taxes  They reported an upward trend from 14.4% in 2004 to the current (2010) 37%  They claimed that one out of three packs of cigarettes are smuggled

Our Concern Cigarette smuggling will lead to the availability of cheaper cigarettes that will counterbalance the effects of tax increases on lowering prevalence because the youth and the poor can now afford it. If tax is lowered due to concern of smuggling, cigarettes will be made more affordable and this can also increase prevalence of smoking.

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

WHAT A GENUINE MALAYSIAN CIGARETTE PACK LOOKS LIKE ? 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

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

Duck to verify the security ink

New tools introduced in late 2009 to verify the security ink

SPECIFIC OBJECTIVES 1.Do illicit products carry a tax stamp or security ink and do these labels follow the government’s specification? 2.Do illicit products carry a health warning and prohibition to minors? 3.Do illicit products carry the message “about 4000 chemical constituents of cigarette”? 4.Are illicit products sold in the same location as legal products? 5.Are illicit products more attractive compared to legal products? Why and among whom? 6.Are illicit products cheaper than the legal products? 7.What is the magnitude of the difference in average price between illicit and legal products? 8.Do illicit products taste better than the legal products? 9.Are illicit product easily accessible to the smokers? 10.Who is more likely to buy illicit products, men or women, urban or rural residents? 11.What are the locally existing illicit packages and their representative companies? 12.Do our illicit cigarette findings different from industry findings?

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

Cross-sectional data of the ITC Wave 4 and wave 5 surveys Conducted between July 2009 and December 2009 for wave 4; and between September 2011 and February 2012 for wave 5 Multi-stage stratified cluster sampling technique

METHODOLOGY Participants were interviewed through telephone; in wave 5 they were asked to provide the bar code number of the cigarette pack that they used at the time of interview Currently used cigarette pack at time of interview were mailed. Total number of factory made cigarette smokers in the study: 1744 (wave 4) and 1605 (wave 5) Total packs received were from 692 smokers (wave 4) & 872 (wave 5) Each collected pack undergone physical observations to identify whether they were genuine or illicit packages. Verification carried out by the custom officers.

CHARACTERISTICS OF RESPONDENTS WHO SENT AND NOT SENT THE PACKS (WAVE 4) CHARACTERISTICSNot ReceivedReceived State (N=1711) Sabah /Sarawak74.5%25.5% Kedah48.5%51.5% Penang56.9%43.1% Selangor63.0%37.0% Terengganu53.4%46.6% Johor67.3%32.7% Residential (N=1711) Urban63.4%36.6% Rural62.4%37.6% Education (N=1578) Primary65.5%34.5% Secondary62.7%37.3% Tertiary59.5%40.5% Age a (sd ) a 32.08(sd-13.02) weighted data. a mean, sd- standard deviation

RELATIONSHIP BETWEEN CHARACTERISTICS OF RESPONDENTS AND PACK SENT OR NOT SENT (WAVE 4) CHARACTERISTICS Univariate P-value OR (95%CI) States n=1711 Sabah & SarawakRef *** Kedah3.09 ( ) Penang2.23 ( ) Selangor1.72 ( ) Terengganu2.55 ( ) Johor1.42 ( ) Residential n=1711 UrbanRef NS Rural1.05 ( ) Education n=1578 PrimaryRef NS Secondary1.12 ( ) Tertiary1.28 ( ) 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 (WAVE 4) CONT... 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 CHARACTERISTICS Univariate P-value OR (95%CI) Income (n=1429) LowRef *** Middle1.23 ( ) High1.04 ( ) Age (n=1711) T-TEST t(1684)=-1.35, p=0.176 a Race (n=1705)MalayRef *** Others0.40 ( ) Employment (n=1479) ProfessionalRef *** Non-Professional3.24 ( ) Technical2.78 ( ) Unemployed2.49 ( )

PERCENTAGE OF ILLICIT PACKS RECEIVED AT WAVE 4 (N=685)

TYPES OF POPULAR CIGARETTES PACKS IDENTIFIED AS ILLICIT (WAVE 4) Total brands as illicit = 16

ILLICIT CIGARETTE PACKAGES RECEIVED BASED ON CHECK LIST (WAVE 4)

RELATIONSHIP BETWEEN CHARACTERISTICS OF RESPONDENTS AND RECEIVED ILLICIT OR GENUINE PACKS (WAVE 4) CHARACTERISTICS Univariate P-value, OR (95%CI) States n=685 Sabah /Sarawak Ref *** Kedah 0.06 ( ) Penang 0.08 ( ) Selangor 0.12 ( ) Terengganu 0.11 ( ) Johor 0.06 ( ) Residential n=685 Urban Ref NS Rural 1.17 ( ) Education n=651 Primary Ref NS Secondary 1.35 ( ) Tertiary 0.89 ( ) Employment n=651 Professional Ref NS Non-Profaessional 1.94 ( ) Technical 1.35 ( ) Unemployed 2.12 ( ) Income n=578 Low Ref NS Middle 0.58 ( ) High 0.36 ( ) 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 (WAVE 4) CHARACTERISTICS Univariate P-value, OR (95%CI) Age n=679 T-Test T(679)=0.018, P=0.985 a Race n=684 Malay Ref *** Others ( ) Reason for choosing particular brand Taste n= 662 NoRef NS Yes0.81 ( ) Price n=664 NoRef*** Yes3.07 ( ) Health n=652 NoRef NS Yes1.28 ( ) 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< a p value independent sample T Test

PLACES WHERE ILLICIT PACKS WERE BOUGHT IN WAVE 4 (N=139)

WAVE 5 DATA: Cigarette Packs Sent. * Unweighted data.

WAVE 5 * Unweighted data.

WAVE 5 * Unweighted data.

Distribution of Non-White Illicit Packs According to Manufacturer * Unweighted data.

Distribution of Non-White Illicit packs according to checklist criteria-Local Manufacturer * Unweighted data.

Distribution of Non-White Illicit packs according to checklist criteria-Foreign Manufacturer * Unweighted data.

CONCLUSIONS The ITC methodology using telephone interview and requesting pack has the potential to provide the types and extent of illicit cigarette use. This method has the potential to provide the profile of people who smoked illicit cigarettes as well as the factors that influence this practice.

ACKNOWLEDGEMENT The ITC-SEA Project is supported by grants P50 CA (Roswell Park Transdisciplinary Tobacco Use Research Center), R01 CA 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 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