THE IMPACT OF GRAPHIC HEALTH WARNINGS ON CIGARETTE PACKAGES

AMONG YOUNG ADULTS WORKING IN PHINMA-UNIVERSITY

OF PANGASINAN

Chapter 1

INTRODUCTION

Background of the Study

Around 19% of adults around the world are currently considered smokers. While the

percentage might be decreasing, by 2030 this percentage will be reduced to 17% compared to

21% in 2015. While in the Philippines, the smoking rate of Filipinos is also decreasing with

25.10% of people aged 15 and above smoking in 2016 and only 24.30% in 2018. This decrease

in smokers might be attributed to better education while also having the availability of

information for public consumption and the awareness of consequences of smoking tobacco,

which means that the Graphic Health Warnings Law or the Republic Act No. 10643 passed by

the government in 2014 is considered a success on its part of effectively informing the public and

providing visual warning of the consumption of tobacco. Despite the reduction of the population

of smoker, it is still considered a problem not only for the smokers but also for people who are

regularly exposed to second-hand smoking which is considered dangerous as smoking a cigarette

in the first place and can still cause various diseases involving the lungs, it can also damage parts

of the body that are not associated with the respiratory system.

According to the World Health Organization (WHO) and the recent analysis of data from

the ITC Four Country Survey that pictorial warnings are cited by former smokers as an important

factor that helped them quit smoking and also contributed to the increase of effectiveness of

cessation services. It is also stated that pictorial warnings can provide longer effects than text-
only warnings. Pictorial warnings are particularly effective on populations with low literacy

rates. It also states that smokers tend to have lower levels of education compared to the rest of

the population. There is also evidence that pictorial warnings are more effective than text-only

warning in low- and middle- income countries because it is one of their few sources of

information involving smoking and the health risk it causes.

The Philippines is not only the country where Graphic Health Warnings are printed on

tobacco packages as currently there are at least 100 countries where Graphic Health Warning is

required to inform the public of the risk of consuming tobacco. The reason why tobacco is a

problem for many is that not only does it cause different chronic diseases like lung cancer but

also that tobacco contains 4000 chemicals with 250 of it can cause harm to people and 50 are

currently known to cause cancer. The biggest problem of these chemicals is the presence of

nicotine which is highly addictive with many of the current smokers unable to quit smoking

despite the Graphic Health Warning printed on cigarette packages and their awareness of the

consequences of continuously smoking. This can also cause problems not only for them but also

to people that are non-smokers but have a regular interaction with smokers whilst their smoking,

for example their family members. Due to nicotine addiction, smokers that are unable to quit

smoking themselves require external intervention not only from their family but also from the

government which is why the government of the Philippines have a smoking cessation program

that can help smokers eventually quit their smoking habits.

The use of tobacco continues to be a major cause of health problems worldwide despite

the availability of information and the printed Graphic Health Warnings as evidence by the

World Health Organization of the yearly death rate of 4.9 million people globally associated with

the consumption of tobacco (The Role of Health Professionals in Tobacco Control, WHO, 2005).
Graphic Health Warnings alone might not be enough to provide a reason to current smokers to

completely quit smoking but it might help prevent people from turning into smokers thus

reducing the population of smokers and effectively reducing cases of diseases which attributes to

the usage of cigarettes. There is a recommendation of policy released by the World Health

Organization in 2003 entitled Policy Recommendations for Smoking Cessation and Treatment of

Tobacco Dependence. It states that it will not be possible to reduce tobacco related death among

the population of smokers over the next 30-50 years unless adult smokers are encouraged to quit.

Population survey reports showed that approximately one third of smokers attempt to quit each

year and that majority of these attempts are undertaken without help and evidence has shown that

cessation is the only intervention with the potential to reduce tobacco-related mortality in the

short and medium term among the population of smokers and therefore should be part of an

overall comprehensive tobacco-control policy of any country.

Education is an important part of the effort reducing the cases of chronic diseases caused

by the consumption of tobacco. According to an overseas study conducted in 1997; ‘’After 11

years of education, the likelihood of smoking decreased and that of smoking cessation increased

with each successive year of education’’ and ‘’that results persisted after the statistical

adjustment for age, sex, ethnicity, poverty status, employment status, marital status, geographic

region, and year of survey’’. Thus, the conclusion is that ‘’the relationship between smoking and

education is not monotonic’’.

The goal of the study is to further reinforce the notion that there is a relation between

education and smoke usage in particular to our study; to show that people working in an

educational environment while having a high educational achievement is a huge factor in

reducing the chance of cigarette usage and increasing the chance of successful nicotine
withdrawal among young adults, even though some might be the exception due to different

factors such as they started the consumption of tobacco in an early age or a family member

influence leading to nicotine addiction. The data can be used to provide information and

awareness of the effectiveness of the Graphic Health Warnings printed on cigarette packages and

the Republic Act No. 10643, while supporting the efforts of the government and health

authorities in educating people about the risk and danger of cigarette usage and cigarette

addiction. This study can be considered as a part of the campaign against smoking.

Given the preceding literatures, the researchers felt motivated to conduct a study on the

impact of graphic health warnings on cigarette packages among young adults working at

Phinma-University of Pangasinan to determine whether the graphic health warnings serve their

purpose in raising fear, educating about the health risks of smoking, and motivating smoking

cessation.

Theoretical Framework

The study will be anchored with the following theories regarding impact of graphic

health warnings.

The Elaboration Likelihood Model focuses on the message processing of a person when

he/she receives a persuasive message. There are two routes that process the message which are

the central route and peripheral route. These two routes lead to persuasion. The central route

involves message elaboration. Elaboration is “the extent to which a person carefully thinks about

issue-relevant arguments contained in a persuasive communication”. In an attempt to process

new information rationally, people using the central route carefully scrutinize the ideas, try to

figure out if they have true merit, and mull over their implications (Griffin, 2013).
 The peripheral route offers a mental shortcut path to accepting or rejecting a message

“without any active thinking about the attributes of the issue or the object of consideration.”

Instead of doing extensive cognitive work, recipients rely on a variety of cues that allow them to

make quick decisions (Griffin, 2013). The Elaboration Likelihood model will allow the

researchers to identify how the smokers process the graphic warnings that they see. The two

routes of the model lead to different effects according to the attitude or motivation of the

smokers.

Another underpinning theory is the Multi-Store Model of Memory. According to Saul

McLeod (2007), the Multi-store model of memory by Atkinson and Shiffrin suggests that our

memory is made up of series of stores and describe memory in terms of information flowing

through a system. It is a one-way model and can also be described as an information processing

model that describes how a person remembers things. Information flows between three

permanent storage systems of memory: the sensory register, short-term memory, and long-term

memory.

The sensory register is where information from the senses is stored but only for duration

of approximately half a second before it is forgotten. But if attended to, the information moves to

the short term memory. It is recorded visually, acoustically, and semantically. It has the capacity

of 5-9 items and stays there for approximately 30 seconds. But if the person chooses to rehearse

the information, it will be consolidated to the long term memory where information can be

retrieved for up to any duration (Turner, 2015).

The Multi-Store Model of Memory will allow the researchers to determine where the

graphic warnings are stored in the memory of the smoker. Each storage system of the memory
will have their own impacts on the smoker and will help the researchers understand the

memorability of the graphic warnings

Conceptual Framework

Figure 1 guided the researchers in analysing the answers of the smokers on how they

remember the graphic health warnings and how these impacted them. It will help the researchers

understand how smokers process the persuasive message that they see in the graphic warnings.

It will also help the researchers determine various factors that affect the impact with each

individual. The graphic warnings are perceived first by the young adults working in Phinma-

University of Pangasinan employees. Then they go to their sensory memory. If they get

motivated to process the message, these now go to their short term memory where they can recall

the information.

After, the ability to process the information now come in, for instances, if there are

distractions or none. If there is the ability to process, it will now go to the smoker’s long term

memory where there will be mental processing of the message that will lead to positive or

negative attitude change. If the smokers are not motivated to process, there are outside factors

that affect the smokers’ decision. It means that if the smokers did not process them, there will be

no impact at all.
 Graphic Warnings on the
Cigarette Pack

Young Adults working at

PHINMA-UoP

YES Message goes to sensory NO

memory

Message goes to short term External Influences

memory (Pleasure, Friends,
(Graphic Warning can be recalled) Problems, etc.)

Ability to process
(Distractions are not present)

Message goes to long term

memory
(Graphic Warning can be remembered anytime)

Type of Mental Processing

(Arguments and attitude)

Strong positive or negative No Impact at all Weak positive or negative

overall impact in habit or
overall impact in habit or
attitude
attitude
 Figure 1: Paradigm of the study

Statement of the Problem

The research aims to determine the impact of graphic warnings on cigarette packages

among young adults working in PHINMA-University of Pangasinan.

Specifically, it seeks to answer the following questions:

1. How frequent do smokers see graphic health warnings?

2. How are graphic health warnings retained in the memory of the smokers?

3. How do smokers remember graphic health warnings?

4. What element of the graphic health warnings do smokers remember the most?

5. How do graphic health warnings influence the smokers’ concept of cigarettes as health

hazards?

6. What is the impact of graphic warnings in their smoking?

Scope and Delimitation

The focus of this study is to determine the impact of graphic health warnings on cigarette

packages among young adults working in PHINMA-University of Pangasinan whose age ranges

from 21 to 39 years old. The researchers delimited the study within the area of D PHINMA-

University of Pangasinan only. The study was conducted by the researchers during the second

semester of the academic year 2020-2021.

Significance of the Study

The result of this research study would hopefully be beneficial for the following

individuals and to the organization:

The university. The results of this study will help the university to provide other related

programs and materials that will help its smoking employees be aware of the risks and negative

effects of smoking.

Human Resource Department. This study will provide the HR department of the

university direction and effort in enhancing the implementation of policies and practices

regarding smoking cigarettes.

University Employees/Cigarette users. This study will help the cigarette users to

comprehend the effects of cigarettes on their health, help them realize the value of Graphic

Health warnings, and convince them to quit smoking.

The researchers/University Students. The study will give awareness as well as

knowledge to the researchers regarding the health risks of smoking.

Future Researchers. This will serve as an informative material for future researchers

and readers on the impact of graphic health warnings on cigarette packages among young adults.

The results of this study will serve as a reference for researchers to conduct further similar

research.

Definition of Terms

Young Adults. The term used in this study refers to the staff of PHINMA-University of

Pangasinan whose age ranges from 21 to 39 years old.

 Graphic Health Warnings. These are photographic images printed on the tobacco

product package which accurately depicts the hazards of tobacco use and accompanied by a

textual warning related to the picture.

Smokers. These refer to the young adults of PHINMA-University of Pangasinan who

smoke cigarette.

Cigarette. A tobacco product in the shape of a tube made of finely cut, cured tobacco

leaves wrapped in thin paper.

 Chapter 2

REVIEW OF RELATED LITERATURE AND STUDIES

The researchers’ analysis of relevant professional literature and studies is discussed in

this chapter. These articles and literature reviews may help to reinforce the reasoning for

undertaking this research, as well as provide a foundation for formulating a problem statement

and exploring the hypotheses and principles that underpin the variables studied.

Cigarette Smoking and Addiction

Smoking is a practice in which tobacco is burned and the smoke is inhaled. Smoking that

contains Tobacco in which tobacco is an agricultural product that forms nicotine, and that nicotine

affects our health. Smoking usually starts during the teenage years, and psychosocial factors provide

the primary forces that lead adolescents to begin. Several aspects of the social environment are

influential in shaping teenagers’ attitude, beliefs, and intentions about smoking. Tobacco is an herb

that can be smoked or chewed, directly affects the brain. While its primary active ingredient is

nicotine, tobacco smoke contains almost 400 other compounds and chemicals, including gases,

liquids, particles, tar, carbon monoxide, cadmium, pyridine, nitrogen dioxide, ammonia, benzene,

phenol, acrolein, hydrogen cyanide, formaldehyde, and hydrogen sulfide. Nicotine is a colorless, oily

compound, and poisonous in concentrated amounts. If you inhale while smoking, 90 percent of the

nicotine in the smoke is absorbed in your body. Even if you draw smoke only into your mouth and

not in your lungs, you still absorb 25 to 30 percent of the nicotine.

 According to World Health Organization (WHO) Global burden disease report, 2012,

The WHO estimates that tobacco caused 5.4 million deaths in 2012 and 100 million deaths over

the course of the 20th century. Similarly, the United States Centers for Disease Control and

Prevention describes tobacco use as “the single most important preventable risk to human health

in developed countries and an important cause of premature death worldwide”.

Baumeister (2017) mentioned that cigarette smoking has become so prevalent in the

country that students have now become heavy consumers. Medical professionals prove that

cigarette smoking among the youth targets them differently from adults. As all are aware,

Nicotine makes it extremely hard for addicted smokers to quit the bad habit. Indeed, the

availability of extremely affordable cigarettes makes it easier for the youth to start smoking and

develop addiction.

The use of tobacco continues to be a major cause of health problems worldwide. There is

currently an estimated 1.3 billion smokers in the world, with 4.9 million people dying because of

tobacco use in a year. If this trend continues, the number of deaths will increase to 10 million by

the year 2020, 70% of which will be coming from countries like the Philippines. The World

Health Organization released a document entitled Policy Recommendations for Smoking

Cessation and Treatment of Tobacco Dependence. This document very clearly stated that as

current statistics indicate, it will not be possible to reduce tobacco related deaths over the next

30-50 years unless adult smokers are encouraged to quit. Also, because of the addictiveness of

tobacco products, many tobacco users will need support in quitting. Population survey reports

showed that approximately one third of smokers attempt to quit each year and that majority of

these attempts are undertaken without help. However, only a small percentage of cigarette
smokers (1-3%) achieve lasting abstinence, which is at least 12 months of abstinence from

smoking, using will power alone (Sabbane, et al 2019) as cited by the above policy paper.

The policy paper also stated that support for smoking cessation or “treatment of tobacco

dependence” refers to a range of techniques including motivation, advice and guidance,

counselling, telephone and internet support, and appropriate pharmaceutical aids all of which aim

to encourage and help tobacco users to stop using tobacco and to avoid subsequent relapse.

Evidence has shown that cessation is the only intervention with the potential to reduce tobacco-

related mortality in the short and medium term and therefore should be part of an overall

comprehensive tobacco-control policy of any country.

The Philippine Global Adult Tobacco Survey conducted in 2009 (DOH, 2011) revealed

that 28.3% (17.3 million) of the population aged 15 years old and over currently smoke tobacco,

47.7% (14.6 million) of whom are men, while 9.0% (2.8 million) are women. Eighty percent of

these current smokers are daily smokers with men and women smoking an average of 11.3 and 7

sticks of cigarettes per day respectively.

The survey also revealed that among ever daily smokers, 21.5% have quit smoking.

Among those who smoked in the last 12 months, 47.8% made a quit attempt, 12.3% stated they

used counseling and or advise as their cessation method, but only 4.5% successfully quit.

Among current cigarette smokers, 60.6% stated they are interested in quitting, translating to

around 10 million Filipinos needing help to quit smoking as of the moment. The above scenario

dictates the great need to build the capacity of health workers to help smokers quit smoking, thus

the need for the Department of Health to set up a national infrastructure to help smokers quit

smoking.
 The national smoking infrastructure is mandated by the Tobacco Regulations Act which

orders the Department of Health to set up withdrawal clinics. As such DOH Administrative

Order No. 122 s. 2003 titled The Smoking Cessation Program to support the National Tobacco

Control and Healthy Lifestyle Program allowed the setting up of the National Smoking Cessation

Program.

The young and the poor, who smoke and drink excessively, are dying every day. Ten

Filipinos die from tobacco use every hour, resulting in 240 deaths every day and 87,600 deaths

every year. This is a health crisis. The main reason is low prices of cigarettes and alcohol. The

Philippines has one of the lowest prices of the two products in Southeast Asia. Because cigarettes

are so cheap, the Philippines have one of the highest smoking rates in the Western Pacific. A

survey showed that 28.3 percent of Filipinos were smokers. It is estimated that some 17.3 million

Filipinos who are 15 years old engage in smoking. To discourage Filipinos from smoking, we

have to raise taxes. Raise the prices of cigarettes and alcohol, and fewer people will buy them.

You cannot argue with the math. Raise the prices of tobacco by 70 percent and you prevent a

quarter of all smoking-related deaths worldwide. Both rich and poor smoke, but it is the poor

who get sick more often. That’s because the poorest sector spends more for tobacco, than for

education, clothing or health. (Philippine Daily Inquirer 2013)

The Constitution is neutral on the use of cigarettes and alcohol. If a Filipino citizen

wants to smoke and if big companies want to make big profits from the so-called “sins” of

smoking and drinking alcohol, they are free to do so. But unlike ordinary citizens, Filipinos who

are members of Congress are not free to ignore the present disastrous chain of circumstances.

Cigarette smoke contains some 70 chemicals which cause cancer. Deaths from stroke and heart

attack are most commonly associated with smoking as a risk factor. In its wisdom, the
Constitution proclaims health as a fundamental right, and accordingly imposes on the state the

duty to protect the people’s right to health and to in still health consciousness. (Philippine Daily

Inquirer 2013)

Tobacco use is one of the major preventable causes of premature death and disease in the

world. A disproportionate share of the global tobacco burden falls on developing countries, where an

estimated 84% of the world's 1.3 billion current smokers live. The Global Youth Tobacco Survey

(GYTS), part of the Global Tobacco Surveillance System (GTSS) initiated by the World Health

Organization (WHO) and CDC, was developed to monitor youth tobacco use, attitudes about

tobacco, and exposure to tobacco smoke, and has been completed by approximately 1.4 million

students in 133 countries.

The latest surveys in the Philippines indicate that one of every three adult Filipinos currently

smoke, 33% of country’s adult population. Another 13% count themselves as ex-smokers. Only four

out of ten Philippine households are smoke-free. With an average of 5.1 members per household,

there would be approximately 35 million passive smokers in the country. Tobacco use in Filipino

youth is alarming. About 30% of adolescents in the urban areas smoke, and of these, more than 70%

started smoking between the ages 13-15. On a national level, the study says that as much as 40% of

boys and 19% of girls aged 10-14 are already daily smokers. The age 15-19, 38% of both male and

female Filipinos are already considered regular smokers (DOH, 2011).

Negative Effects of Smoking

Tobacco product is defined as any manufactured product made of leaf tobacco this used

for smoking, sucking, chewing or snuffing (WHO, 2011). There are three types of tobacco

preparation. The first one is the roll of tobacco which is smoke. Cigarette is the best example of

this. The second type is pipe like water pipes. The third is the oral preparation which chewed,
held in mouth or place in nose. Examples are snuff, snus, betel and quid. Tobacco contains

nicotine and many carcinogens. Hence, it is an addictive plant . Scientific evidence show that the

consumption and exposure to tobacco smoke cause this three: (1) Death (2) Disease and (3) 16

Disability. Aside from this it has been found out that there is a time interval between the

exposure to smoking and the start of tobacco-related diseases . Smoking indeed causes pre-

mature death around half of the continuing of the cigarette smokers which are approximately 650

million people, who are still alive will sooner or later die from tobacco-related disease if they

still smoke.

At the moment, developing countries are bearing a disproportionate share of the burden

of tobacco-related diseases and deaths (WHO 2012). Cigarettes are widely regarded as one of the

most lethal and addictive products ever devised by man. If users smoke cigarettes in accordance

with the manufacturers' intentions, cigarette smoking can kill half of its users. On the other hand,

it is not just tobacco users who are vulnerable to its negative effects. Secondhand tobacco smoke,

also known as passive smoking, has exposed millions of people to the harmful effects of tobacco

consumption, including half of the world's children. Evidence connects second-hand smoking to

an increased risk of cardio-vascular diseases, lung cancer and other types of cancer. Asthma, and

other respiratory diseases, ear infection and sudden infant death syndrome in children.

The diseases listed above are just a few of the negative effects of secondhand smoking

(WHO 2012) Because the tobacco epidemic is spreading rapidly, tobacco product regulation is

critical. Aside from being harmful and addictive, all tobacco products can cause disease and

death (WHO, 2012). Tobacco consumption is hazardous to both smokers and nonsmokers. It is

harmful to children, causing respiratory problems and other health issues.

 Annually, second-hand smoke causes an estimated 3000 lung cancers deaths and 62,000

coronary heart disease in California . All tobacco products are dangerous and addictive.

Government the use of tobacco in any form as well as to raise awareness about its harmful and

deadly effects (WHO 2012). However, in order to maintain profit, tobacco companies continue

to develop new products. These companies cover the tobacco products harmful effects of

portraying tobacco products as attractive and less harmful.

Cigarette smoking produces a complex, dynamic, and reactive mixture of approximately

5,000 chemicals, according to Gashaw et al (2016). It is one of the leading preventable causes of

respiratory tract complications, disability, and premature death worldwide (WHO, 2015). It is

responsible for six of the top eight causes of morbidity and mortality. Essentially, it is a legal

drug that kills a large number of its users when used exactly as the manufacturers intended.

Currently, the World Health Organization (WHO) estimates that smoking and smokeless tobacco

use account for approximately 6 million deaths worldwide each year, with 600,000 deaths

occurring among nonsmokers as a result of exposure to tobacco. More than 30% of world’s adult

population are consumers of tobacco, which leads to a warning that a billion people will die of

adverse health effects related to the tobacco epidemic within the 21st century unless effective

preventative measures are undertaken

Smoking harms almost every organ in the human body (including the circulatory,

respiratory, gastrointestinal, and musculoskeletal systems), increases the risk of several diseases,

and impairs smokers' overall health (WHO, 2015). According to Tesfahun et al (2013), the main

effect of smoking cigarettes is primarily on the lungs, with smoking being responsible for

approximately 85 percent of chronic obstructive pulmonary disease (COPD) and lung cancer and
approximately 33 percent of other cancers (i.e., esophagus, oral cavity, uterus, stomach, and

pancreas).

According to Gina Tomé et al (2012), normal adolescent development is influenced by

high levels of peer pressure, which can influence risk-taking behaviors such as substance use.

Tobacco-related morbidity and mortality affect an estimated 80% of the world's one billion

adolescent smokers, particularly in low- and middle-income countries. Cigarette smoking has a

negative impact on an individual's physical and mental health (Fit for Work team, 2017). This is

especially true for high school and university students, who are already dealing with major health

issues such as stress (Tesfa, et al , 2017). Smoking is also linked to poor academic performance,

high-risk drinking, illegal drug use, and high-risk sexual behavior. Peer pressure is widely

acknowledged as a significant factor influencing young people's early tobacco experimentation

and willingness to continue smoking. According to Lussier (2015), several students at higher

education institutions smoke cigarettes for a variety of reasons, including stress relief. Being

male, drinking alcohol, having a friend who drinks alcohol, having a friend who smokes, having

family members who smoke, and being older in age are all factors that contribute to the

continued use of tobacco.

Lin et al. (2017) discovered that smokers have an increased risk of periodontal disease,

tooth loss, and oral cancer. Nicotine, which is a major component of cigarettes, inhibits the

proliferation of RBC, macrophages, and fibroblasts, all of which are important components of

healing. According to Yamano et al. (2014), smoking increases platelet adhesiveness, which can

lead to poor perfusion due to micro clots. It also acts as a sympathomimetic, increasing the

release of epinephrine and norepinephrine and causing increased vasoconstriction, limiting

overall tissue perfusion. Several researchers hypothesized that smoking hampered wound

healing.

The effect of smoking on bone regeneration has been established by studies (Angeles

Sanchez et al, 2011), which found that success of bone regeneration in nonsmokers can reach 95

percent, whereas it is only 65 percent in smokers. Tobacco use over a lifetime has been linked to

bone quality deterioration. The smoking group had a higher incidence of marginal bone loss,

which was more pronounced in the maxilla.

There is also mounting evidence that oral dysbiosis plays a role in systemic diseases of

the lung (Beck et al., 2012), digestive tract (Ahn et al., 2012), and cardiovascular system (Koren

et al., 2011), but the factors that influence the oral microbiome remain unknown. Cigarette

smoke contains numerous toxicants that come into direct contact with oral bacteria (WHO,

2012); these toxicants can disrupt the microbial ecology of the mouth through antibiotic effects,

oxygen deprivation, or other potential mechanisms. The loss of beneficial oral species as a result

of smoking can lead to pathogen colonization and, eventually, disease; this contention is strongly

supported by the well-established role of smoking. (Nociti et al., 2015)

What is Graphic Health Warning?

According to Mackay et al. (2013), Asia, with its diverse political systems and large

population, has the highest number of tobacco users and is the primary target of transnational

tobacco industries, particularly in China, India, and Indonesia. To address the tobacco issue in

Asia, the World Health Organization (WHO) has aided the continent's member states in

implementing WHO's Framework Convention on Tobacco Control (FCTC), which entered into

force in 2005. FCTC is a set of global standards and guidelines for tobacco policy among WHO
members that, by 2011, had successfully improved tobacco control policies in 120 of 174

countries. According to Aditama et al. (2018), the WHO's FCTC is the first global tobacco-

control treaty that encourages ratifying countries to develop and implement tobacco-control

policies in their own countries, such as regulating tobacco advertising, tobacco tax and price,

smoke-free zones, and health warning messages on tobacco packages.

According to Fathelrahman et al (2017), graphic health warnings, which make the

potential for smoking to cause diseases more real to smokers, can both improve public

knowledge and work to encourage cessation through the generation of concern stimulated by

emotionally charged messages. The use of pictorial warnings is especially important in low-

literacy countries (Balhara et al, 2015). Scollo and Winstanley (2018) discovered that smokers

who smoked 20 cigarettes per day would be exposed to health warnings approximately 7000

times per year. According to studies conducted in the United States, recognition of warnings in

pictorial health warnings was higher than recognition of warnings in text-only warnings.

Furthermore, the lung cancer warning deterred adolescent nonsmokers from wanting to smoke.

According to Cameron et al. (2015), pictorial warnings have been found to be effective in

deterring smoking, particularly among the young. However, Li, Chan, and Lam (2015)

discovered that current, ex-, and never smokers thought smoking cessation advertisements were

less powerful than anti-drug advertisements in a study on smoking behavior among Hong Kong

Chinese women. Despite this, current and former smokers in the study were aware of pictorial

health warnings on cigarette packs depicting varying degrees of horror and disgust. Evidence,

however, found the large health warnings, as it has been documented that larger health warnings

covering more of the front of the pack have a greater effect.

 It is also supported by psychological theories that argue that larger warnings are more

likely to be remembered (Strahan, et al, 2012). Furthermore, it was discovered that regularly

refreshing the images on pictorial health warnings over time helped to sustain the effects on

smokers.

Effects of Graphic Health Warning to the smokers.

Despite the expense, anti-tobacco mass media campaigns can be more cost effective than other

interventions and have a greater impact because they reach large populations quickly and efficiently

(DOH, 2011).

Tobacco Regulation Act of 2003 (Republic Act No. 9211) prohibits smoking in all public

places and tobacco sales within 100 meters of schools, playgrounds, and other youth-oriented

facilities. It requires retailers to request proof of age from cigarette buyers and to post signs stating

that selling cigarettes to anyone under the age of 18 is illegal. By July 1, 2008, all sponsorship will

be prohibited. Violations of this new Act will result in fines ranging from 500 pesos to 5,000 pesos.

Tobacco companies have planned ahead of time for these restrictions. In 2004, for example, a

British American Tobacco brand manager stated that future marketing would be focused on one-to-

one “permission marketing” to counteract restrictions placed on mass media strategies. Consumers

give marketers permission to send them promotional messages, which improves targeting precision.

“Permission marketing enables us to communicate with consumers on their level, on their turf.”

Furthermore, Republic Act No. 9211 mandated the establishment of an Inter-agency

Committee on Tobacco (IAC-Tobacco). Its responsibilities included the creation of the

implementing rules and regulations (IRR) for the aforementioned law, as well as the subsequent

exclusive power of administration and implementation. The IAC-Tobacco is made up of nine

members: seven from government agencies, one from the tobacco industry, and one from a non-
governmental organization. The National Tobacco Administration has a long history of tobacco-

friendly policy. Anti-tobacco activists have also labeled the Department of Trade and Industry,

which oversees the IAC-Tobacco, as pro-tobacco. According to the World Health Organization,

“continuing efforts to enact comprehensive legislation have yet to achieve victory” in the

Philippines.

According to Cantrell et al. (2013), no two anti-smoking advertisements were alike. According

to Cantrell et al. (2013), no two anti-smoking advertisements were alike in terms of their

characteristics, thematic content, and the level to which they engaged youth or how youth were

likely to respond. Advocates attempting to develop increasingly successful anti-smoking campaigns

should take into account the characteristics of proposed advertisements. The use of personal

testimonials, visceral negative executions, or both, with themes of health effects may increase the

likelihood that fewer young people will smoke in the future. To have a successful message, the

format and approach must be taken into account.

Fong et al. (2016) discovered a significant effect of anti-smoking advertising on television in

the progression to smoking during a four-year period that was specific to younger adolescent but

found no significant effect of exposure to radio or outdoor advertisement. He also discovered that

youth exposed to anti-smoking television advertisements were more likely to have an accurate

perception of youth smoking prevalence as opposed to an infatuated perception. Only the younger

adolescent showed a significant effect. According to the study, television was the most widely used

medium for anti-smoking campaigns. As a result, youths were more likely to be informed by

watching. In order to address the issue, the WHO framework convention was made. This aims to

reduce the disease and death burdens caused by tobacco (WHO 2012). Article 20 of this framework
convention encourages anti-smoking advertising. This article is about achieving product regulation

goals through research, surveillance, and information exchange.

Pictorial warning labels are one type of anti-smoking advertisement. These pictorial warning

labels are said to be an important way to communicate the dangers of tobacco use. Because tobacco

companies use tobacco packages to promote their products, pictorial warning labels are essential.

Drawing evidence suggests that larger, bolder, and pictorial warning labels have an effect on people.

Many countries introduce stronger labels; evaluation shows that effective warning labels increase

knowledge about the smoking risk as well as it can persuade smokers to quit (Hammond, 2011).

It has been discovered that smokers receive more information about smoking risks from

tobacco product packaging than from any other source except television (Hammond, 2011). Tobacco

product warning labels with images raise awareness of the dangers of tobacco consumption, reduce

adolescent smoking intentions, and encourage smokers to quit. These labels serve as a counter-

argument to the tobacco industry's advertisements. Pictorial warning labels were found to have a

greater impact than text-on-the-labels.

Children and low-literacy audiences may be able to recognize these pictorial warning labels.

According to Hammond (2011), smokers are exposed to images printed on packs at least 20 times

per day (every time they buy a cigarette). This exposure provided an opportunity to deliver an anti-

smoking message at a critical stage, which was the smoking period. As a result, the use of pictorial

images boosted the impact of the anti-smoking message. On the other hand, even in countries with

widespread anti-smoking campaigns, public awareness of the true dangers of smoking is low.

Borland, et , al (2019). Nonetheless, exposure to anti-smoking media messages is increasing in

comparison to pro-smoking media messages.

 Previous research has found that graphic warning labels have a greater impact than text-only

warnings across a wide range of racial/ethnic and socioeconomic populations. Given their wide

reach, graphic warning labels may be one of the few tobacco control policies with the potential to

reduce communication gaps between groups. Policies that require strong graphic warning labels on

tobacco packaging may help to reduce the toll of the tobacco epidemic, especially in vulnerable

communities.

Data from the International Tobacco Control (ITC) Policy Evaluation Project, a prospective

longitudinal panel study of smokers in multiple countries (Hammond, 2011), demonstrate that

graphic warnings are more likely to be noticed than text-only warnings (Thrasher, et al,2011) more

effective in informing viewers of the risks of smoking and more likely to motivate quit-related

activity. Experimental work is limited, but evidence suggests that graphic warnings outperform text-

only warnings on a range of outcomes, including capturing attention (Azagba, et al , 2013),

increasing awareness of health risks , and creating unfavorable associations with smoking as well as

perceived effectiveness , negative affect, and motivation to quit.

Other researchers point to shortcomings of the existing empirical evidence and are less

convinced that graphic warning labels are effective in their intent to promote cessation. Ruiter and

Kok (2013) argued that the evidence is sparse and unconvincing, and find flaws in the current

research such as poor controls for mediating variables. They point out the lack of longitudinal

evidence comparing attitudes toward smoking and smoking trends prior to and following the

implementation of graphic labels in a specific population. Furthermore, there is some evidence that

graphic warnings incite defensiveness in response to fear-arousing information.

Problems may arise when the fear induces a more pressing concern while curbing the

immediate experience of fear, often by attempting to undermine the importance or credibility of the
message. Self-affirmation theory states that people are fundamentally motivated to protect their

sense of self-integrity. This is the motive that is most aroused by threatening material, such as

graphic warnings, and is satisfied by defensiveness (Harris, et al , 2017). Whether graphics or text-

only warnings are implemented, message framing is central to the effectiveness of labels.

Loss-framed messages emphasize the negative consequences of a behavior while gain-framed

messages emphasize how one can avoid the undesirable outcome. The difference between gain

framed avoidance and gain framed benefits is that the former emphasizes the threat one can avoid by

not smoking while the latter emphasizes the pure benefits 5 of not smoking (Goodall,, et al , 2017).

Graphic cigarette labels have been criticized for being loss-framed, and have raised concerns of the

incitation of avoidance tactics, such as covering cigarette packs or purchasing loose cigarettes, and

possibly lead to other adverse effects.

Some research has suggested that warning labels would be more effective if they created a

strong positive attitude toward quitting, while concurrently promoting a negative attitude towards

smoking. With regard to process principles, color and brightness are one way to draw attention to

warning labels; these tactics are also utilized by tobacco companies as a marketing technique. Bright

colors tend to attract attention and prompt smokers to consider the content of the message. Bansal-

Travels et al. (2018) conducted a study to examine the potential impact of pack design on risk

perception and brand appeal. Results showed that participants selected larger, graphic, and loss-

framed warning labels as more likely to attract attention, encourage thoughts about health risks,

motivate quitting, and be most effective. Participants were more likely to select packs with lighter

color shading and descriptors such as light, silver, and smooth as delivering less tar, smoother taste,

and lower health risk, compared to darkershaded or full-flavor packs. Another issue, overexposure or
 wear-out, is a problem for any message that is presented repeatedly over time. A message’s

effectiveness tends to increase over the first few exposures, but then diminishes over time.

Studies have found that people exposed to newly designed warnings are significantly more

likely to retain the message or concept of the newer warning label as compared with older labels.

Other studies found that individuals exposed to newly designed warnings were 6 significantly more

likely to remember the concept of the warnings than individuals exposed to old mandated warnings.

Research has suggested that a variety of anti-smoking messages would be effective, and such a

strategy would also address this over-exposure problem.

Chapter 3

RESEARCH METHODOLOGY

This chapter explains the research design used, subjects of the study and sampling

scheme, data gathering procedures, and the statistical treatment.

Research Design

The researchers will employ a descriptive method of research whose main

objective/purpose was to determine factors considered by employers on employees’ retention.

The survey questionnaire was the main instrument in gathering data. The descriptive was used

because it includes finding out direct responses from the respondents through the survey
questionnaires. It supports the assertions and definitions which made by the noted authors which

conformed to the description of the present study.

Furthermore, the type of descriptive research that the researcher used was the survey

type. Manuel & Medel (2016) defined survey research as a method which investigates a

universe of phenomena population by selecting sample from the population to discover the

relative incidence, distribution and interrelation of variables. With the survey method the

researcher had an interaction with the respondents and guide them, when necessary in answering

the questionnaire.

The researchers will utilize a questionnaire survey in the data gathering. The rationale for

adopting survey design allowed the collection of data using a questionnaire at a particular point

in time from a sample of participants and from a target population in order to determine the

current status of that population with respect to one or more variables (Orodho, 2009).

Sources of Data

The respondents of the study will be young adults working in the University of

Pangasinan whose age ranges from 21-39. The researcher used the Slovin’s Formula to compute

for the sufficiency of sample size. The margin of error, the amount of error the researcher can

tolerate is at 5% and the confidence level, the amount of uncertainty that the researcher can

tolerate is 95%. The sample was determined using purposive sampling technique to allow for a

representative sample, avoid bias and reduce sampling errors.

Data Gathering Instrument

The researchers will use survey questionnaire. The questionnaire included 5 point Likert

scale and multiple choice questions to measure the impact of graphic health warnings on

cigarette packages to the smokers.

 For the purpose of making the questionnaire more valid, the researchers will seek help

from at least three (3) people who are competent in the subject matter for suggestions for the

improvement of the data gathering tool. After the refinement of the questionnaire, the researchers

will ask permission from the university to administer the approved questionnaire to the identified

respondents.

The researchers will create a Google Form for the approved questionnaire for easy and

quick tabulation. At the same time, with regards to the health protocol provided by Department

of Health and IATF, the respondents of the study will be contacted online. The researchers will

send the link to the targeted respondents via email and social media such as Facebook and the

like to avoid face-to-face conduct of survey. The online survey form will be opened until the

total number of sample needed for the study was reached.

Tools for Data Analysis

The data will be gathered through a survey-questionnaire and will be analyzed and

interpreted to provide answers to the problems embodied in this study. The data which were

gathered by the researcher were subjected to appropriate statistical treatment for interpretation.

Different sub-problems were statistically treated.

For sub-problems 1- 5, frequency count and percentage will be used. Frequency count is

the most straightforward approach to working with quantitative data. Items are classified

according to a particular scheme and an arithmetical count is made of the number of items (or

tokens) within the text which belong to each classification (or type) in the scheme. This method

tabulates how many times a certain variable occurs within a calculation.

The process of creating a frequency count involves first identifying the total number of

observations to be represented; then counting the total number of observations within each data
point or grouping of data points; and then dividing the number of observations within each data

point or grouping of data points by the total number of observations.

Data collected in sub-problems 1–5 will be presented using charts to make it easier to

understand.

Sub-problem 6 will be treated using the average weighted mean. The average weighted

mean is a type of mean that is calculated by multiplying the weight (or probability) associated

with a particular event or outcome with its associated quantitative outcome and then summing all

the products together. It is very useful when calculating a theoretically expected outcome where

each outcome shows a different probability of occurring, which is the key feature that

distinguishes the weighted mean from the arithmetic mean.

To interpret sub-problem 6, the scale below will be used.

Scal Statistical
e Range Descriptive Equivalent Descriptive Equivalent
5 4.50-5.00 Strongly Agree (SA) Very High Level of Impact
4 3.50-4.49 Agree (A) Moderately High Level of Impact
3 2.50-3.49 Uncertain (U) Average Level of Impact
2 1.50-2.49 Disagree (D) Moderately Low Level of Impact
1 1.00-1.49 Strongly Disagree(SD) Low Level of Impact
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 Questionnaire
PART 1: Graphic Health Warning
General Directions: Read each item carefully. Check and rank your preferred answer.
1. How frequent do you see graphic health warnings in the following? Rate the following
possible medium according to how frequent you see GHWs.

Never Seldom Sometimes Often Always

Package Itself
Posters and other Collaterals
TV and Print Advertisements
Point of Sales
Online
2. How is graphic Health warnings retained in your memory?

Permanently
Fleetingly
Off and On
Forgotten
Others (Please specify):

3. How do you remember graphic health warnings?

Vividly
Partly
Vaguely
Confusingly
Not at all
Others (Please specify):

4. What element of the graphic do you remember the most? Rate the following depending on its
level of memorability.

Not at all Slight Moderately Very Extremely

memorable memorable memorable memorable memorable
Image
Text/Copy
Color
Font
Size
Layout

5. How do graphic health warnings influence your concept of cigarettes as health hazards?

Not at all hazardous Slightly hazardous

 Moderatel
y
hazardous

Very
hazardous

Extremel
y
hazardous
Part II: Impact of Graphic Health Warning

Please check one in each column corresponding on to how you rate each objective in

terms of the impact the graphic health warnings have on you as a smoker.

Scale Descriptive Equivalent

5 Strongly Agree (SA)
4 Agree (A)
3 Uncertain (U)
2 Disagree (D)
1 Strongly Disagree (SD)

S
Indicators A A U D SD
My awareness to graphic health warnings made me . . . 5 4 3 2 1
1. think to quit smoking.          
2. raise my concerns about smoking          
3. reduce how much I smoke          
4. not buy or postpone buying another pack of cigarettes          
5. think about dangerous effects of smoking in my health          
6. influence my family, colleagues and friends to quit smoking.          
7. think about future consequences of smoking when I get older.          
8. aware of the negative effects of smoking.          
9. seek professional assistance regarding my smoking habits.          
10. smoke more (did not have impact on me)          
 Content Validity

Direction: This tool asks for your evaluation of the questionnaire to be used in the data gathering
for the investigation stated above, to establish its validity. You are requested to give your honest
assessment using the criteria stated below; please check (/) only one from the selection.

Scale Interpretation Description

5 Very High Valid The questionnaire is valid and can provide unbiased data for
investigation, allowing 0-5% error
4 High Valid The questionnaire is valid and can provide unbiased data for the
investigation, allowing 8-10% error
3 Valid The questionnaire is valid and can provide unbiased data for the
investigation, allowing 16-20% error
2 Less Valid The questionnaire is valid and can provide unbiased data for the
investigation, allowing 16-20% error
1 Not Valid at all The questionnaire is valid and can provide unbiased data for the
investigation, allowing 211-25% error

Validators’ Questionnaire Assessment

Indicators 5 4 3 2 1
The indicators in the questionnaire consistently and accurately measure
each variables of the investigation
The questionnaire fits with the variables under investigation, thus
measuring what it tends to measure
The questionnaire has the capability to measure items of variables within a
given time frame
The questionnaire has the ability to distinguish the characteristics or the
properties of differing attributes of the subjects under study
The questionnaire has the ability to gather factual data, eliminating biases
and subjectivity
Quick and complete data can be generated by the questionnaire within the
time frame allowed to obtain the data
The questionnaire has no influence on the variables being measured
The questionnaire is framed in a clear, simple, in order to avoid risk of
error
The questionnaire is capable of generating data that will be of value and
practical use to the sectors concerned in the investigation

Comments and Suggestions:

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Signature over Printed Name