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Cigarette package health warnings and interest in quitting smoking - 14 countries, 2008-2010.

The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) requires health warnings on tobacco product packages sold in countries that ratified the WHO FCTC treaty (1). These warnings are expected to 1) describe the harmful effects of tobacco use; 2) be approved by the appropriate national authority; 3) appear on at least 30%, and ideally 50% or more, of the package's principal display areas; 4) be large, clear, visible, and legible in the country's principal language(s); 5) have multiple, rotating messages; and 6) preferably use pictures or pictograms. To assess the effects of cigarette package health warnings on interest in quitting smoking among smokers of manufactured cigarettes aged [greater than or equal to]15 years, this report examines 2008-2010 data from the Global Adult Tobacco Survey (GATS) in 14 WHO FCTC countries. Among men, the prevalence of manufactured cigarette smoking ranged from 9.6% in India to 59.3% in Russia. Among men in 12 of the countries and women in seven countries, >90% of smokers reported noticing a package warning in the previous 30 days. The percentage of smokers thinking about quitting because of the warnings was >50% in six countries and >25% in men and women in all countries except Poland. WHO has identified providing tobacco health information, including graphic health warnings on tobacco packages, as a powerful "best buy" in combating noncommunicable disease (2). Implementing effective warning labels as a component of a comprehensive approach can help decrease tobacco use and its many health consequences.

GATS is a nationally representative household survey conducted among persons aged [greater than or equal to]15 years using a standardized questionnaire, sample design, data collection method, and analysis protocol to obtain measures on key tobacco control indicators and ensure comparability across countries.* GATS was conducted once in each of the 14 countries during 2008-2010 by national governments, ministries of health, survey-implementing agencies, and international partners. In each country, a multistage cluster sample design is used, with households selected proportional to population size. Data are weighted to reflect the noninstitutionalized population aged >15 years in each country. For this analysis, current smokers of manufactured cigarettes^ were asked whether they had noticed health warnings on a cigarette package in the previous 30 days, and whether the label led them to think about quitting smoking. [section] Responses were analyzed by sex and, within sex strata, by age and education level using bivariate analysis within individual countries. Differences in response estimates were considered statistically significant if 95% confidence intervals did not overlap. Overall response rates ranged from 65.1% in Poland to 97.7% in Russia.

The health warnings on cigarette packages in each country at the time GATS was conducted were described according to WHO FCTC guidelines (3,4). All GATS countries had warning labels on cigarette packages describing harmful effects of smoking at the time their survey was conducted. Four of the 14 countries (Brazil, Egypt, Thailand, and Uruguay) had pictorial warnings. A fifth country, India, introduced pictorial warnings in 2009, and had both text and pictorial warnings in circulation when GATS was conducted (Table 1).

In all 14 countries, men were more likely to be cigarette smokers than women. Among men, prevalence of smoking ranged from 9.6% in India to 59.3% in Russia (Table 2). Among women, prevalence of smoking was <25% in all countries and <2% in Bangladesh, China, Egypt, India, Thailand, and Vietnam.

In all countries except India (78.4%) and Mexico (83.5%), >90% of men reported noticing a health warning on a cigarette package (Table 2). Among women, the percentage who noticed warnings was [greater than or equal to]75% in all countries except China (60.1%) and India (18.9%), and >90% in seven countries. In Bangladesh and Egypt, not enough women reported current smoking to calculate this percentage.

Smokers aged [greater than or equal to]65 years were less likely to notice warnings in Bangladesh (men), Brazil (men and women), Mexico (men), Philippines (men and women), Thailand (men), and Ukraine (men) (Table 2). Smokers who had not completed primary school education were less likely to have noticed warnings in Bangladesh (men), China (men and women), India (men), Mexico (women), Philippines (men and women), Turkey (women), and Vietnam (men) (Table 2).

Among smokers who noticed a package warning, the percentage thinking about quitting because of the warning was >50% in six GATS countries (Bangladesh, Brazil, India, Thailand, Ukraine, and Vietnam) and >25% for men and women in all countries except one (Poland). Older male smokers were less likely to think about quitting in India and Uruguay; no other age group differences were noted.

Editorial Note

This report is the first to provide survey results from all 14 countries that participated in GATS during 2008-2010. In these countries, the prevalence of smoking manufactured cigarettes varied widely and was more common among men. Warning the public about the dangers of tobacco is one of the strategies in WHO's MPOWER package to combat the tobacco epidemic (3). Most of these countries had met the minimum WHO FCTC health warning label criteria for cigarette packages at the time GATS was conducted. The majority of smokers noticed the health warnings, and in most countries >25% who noticed the warnings said they were led to think about quitting. These results indicate that package warnings can be effective for various populations and settings, including countries in which cigarette smoking prevalence currently is low.

To be effective, cigarette package warnings must capture smokers' attention and educate them about the health effects of tobacco use (5). The WHO FCTC guidelines provide parameters to accomplish these objectives by emphasizing features that increase the salience of warnings (1,4). Prominent, pictorial warnings have been found to be the most effective in communicating the harms of smoking in several studies (4,6). Smokers who perceive a greater health risk from smoking are more likely to think about quitting and to quit successfully (6). Further, evidence indicates that warnings are more likely to be effective if they elicit strong emotions, such as fear, seem personally relevant, and increase confidence in the ability to quit (4,7). For example, a comparative analysis of responses to labels in Brazil, Mexico, and Uruguay found that the Brazilian warnings depicting human suffering had the strongest impact on thinking about quitting (8). Rotating warnings also is important because the impact of an individual label will decrease over time (5). Thus, a warning that is small in total size or font size, has been in circulation for a long time, or lacks informational content that generates an emotional response likely will not have the strongest possible impact.

Graphic warnings have the potential to reach those who do not notice or read text-only warnings; they also have the potential to better evoke emotional responses, increase knowledge of health risks, and reinforce motivations to quit smoking (9). Therefore, the WHO FCTC guidelines strongly encourage the use of graphic warnings (5). Low education level and older age were associated with not noticing warnings in some countries; virtually all of these countries had text-only warnings. Women were less likely to notice warnings than men in India, China, and Vietnam, countries where cigarette smoking prevalence is very low among women. These findings emphasize the importance of using warnings that are effective in communicating the risks of smoking to all cigarette smokers and using other evidence-based tobacco control measures that reach populations that are not frequently exposed to cigarette packages.

Warnings were more effective at getting smokers to think about quitting in some countries than in others. Brazil and Thailand, countries with numerous prominent and graphic pictorial warnings in rotation, had among the highest prevalences of smokers thinking about quitting because of the warnings; these warnings received WHO's highest rating (3). However, reported thinking about quitting smoking also was relatively high in Bangladesh and Vietnam, where warnings covered less of the package and were text-only. The reasons for these findings are not immediately clear but might relate to the relative importance of package warnings among other contextual factors such as smokers' baseline knowledge about health risks, level of interest in quitting, and level of tobacco dependence, as well as concurrent tobacco control efforts and social norms surrounding tobacco use (7). Further research might be helpful in elucidating these factors and in determining the extent to which thinking about quitting because of warnings leads to quit attempts in GATS countries.

The findings in this report are subject to at least five limitations. First, all data were self reported, and social norms (e.g., unacceptability in some countries of women smoking) might have affected responses. Second, the education categories used in Brazil are not comparable to the categories used in this analysis, so Brazil's data were not evaluated for differences in prevalence by education. Third, this analysis included only smokers of manufactured cigarettes; however, other tobacco products (e.g., bidis, kreteks, hand-rolled cigarettes, waterpipes, and smokeless tobacco) are commonly used in India and other GATS countries. Fourth, the prevalence of smoking among women is low in some countries, so analyzing or interpreting results on the impact of package warnings among women was not possible. Finally, GATS was not designed to evaluate the effectiveness of individual health warning labels, and its core questions did not distinguish between the different labels in circulation in a country.

After GATS was conducted, Mexico, Philippines, Turkey, and Ukraine passed legislation requiring pictorial warning labels, and Thailand and Uruguay increased the size of their warnings. Worldwide, a majority of countries now have warnings on cigarette packages, but their features and strength vary (7). As of 2010, approximately 30 countries had pictorial warning labels covering at least 50% of the package (7), and additional countries were developing such labels.' Future GATS will allow tracking of progress toward key tobacco use and control indicators. Smokers view their cigarette packages every time they remove a cigarette; therefore, the cigarette package represents a powerful vehicle to deliver health warnings directly to smokers. Nonsmokers and former smokers also can be discouraged from smoking by viewing comprehensive warnings (7).

WHO has identified price increases; smoke-free policies; bans on tobacco advertising, promotion, and sponsorship; and providing tobacco health information via mass media campaigns and graphic health warnings to the public as tobacco "best buys"** because they can reduce tobacco initiation, help to prevent progression from initiation to addiction, increase cessation, decrease consumption, and change social norms (2). Providing information about the dangers of using tobacco products with package warnings is a simple and cost-effective strategy to motivate quit attempts, thus helping to prevent the life-threatening effects of tobacco use (9,10).

What is already known on this topic?

Warning the public about the dangers of tobacco is one of the key strategies in the World Health Organization's MPOWER package to combat tobacco use.

What is added by this report?

For the first time, data from all 14 Global Adult Tobacco Survey (GATS) countries are available. In these countries, the prevalence of smoking manufactured cigarettes varies widely and is more common among men. The majority of smokers noticed package warning labels. Among smokers who noticed a health warning, the percentage thinking about quitting because of the warning was >50% in six GATS countries.

What are the implications for public health practice?

Strong health warning labels on cigarette packages are effective in motivating smokers to consider quitting. These findings emphasize the importance of using warnings that are effective in communicating the risks of smoking to all cigarette smokers.

Acknowledgment

David Hammond, Univ of Waterloo, Ontario, Canada.

References

(1.) World Health Organization. WHO Framework Convention on Tobacco Control. Geneva, Switzerland: World Health Organization; 2005. Available at http://www.who.int/fctc/en. Accessed May 22, 2011.

(2.) World Health Organization. Global status report on noncommunicable diseases, 2010. Geneva, Switzerland: World Health Organization; 2011. Available at http://www.who.int/nmh/publications/ncd_report2010/ en/index.html. Accessed May 22, 2011.

(3.) World Health Organization. "WHO report on the global tobacco epidemic, 2009: implementing smoke-free environments. Geneva, Switzerland: World Health Organization; 2009. Available at http://www.who.int/ tobacco/mpower/2009/en/index.html. Accessed May 22, 2011.

(4.) World Health Organization. Conference of the Parties to the WHO Framework Convention on Tobacco Control, third session. Geneva, Switzerland: World Health Organization; 2009. Available at http://apps.who. int/gb/fctc/pdf/cop3/fctc_cop3_rec1-en.pdf. Accessed May 22, 2011.

(5.) US Department of Health and Human Services, Food and Drug Administration. Required warnings for cigarette packages and advertisements. Federal Register 2010;75:69524-65.

(6.) Hammond D, Fong GT, McNeill A, Borland R, Cummings MK. Effectiveness of cigarette warning labels in informing smokers about the risks of smoking: findings from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 2006;15(Suppl III):iii19-25.

(7.) Hammond D. Health warning messages on tobacco products: a review. Tob Control 2011. In press.

(8.) Thrasher JF, Villalobos V, Szklo A, et al. Assessing the impact of cigarette package health warning labels: a cross-country comparison in Brazil, Uruguay and Mexico. Salud Publica Mex 2010;52(Suppl 2):S206-15.

(9.) Hammond D, Fong GT, Borland R, Cummings KM, McNeill A, Driezen P. Communicating risk to smokers: the impact of health warnings on cigarette packages. Am J Prev Med 2007;32:202-9.

(10.) Borland R, Yong H, Wilson N, et al. How reactions to cigarette packet health warnings influence quitting: findings from the ITC four-country survey. Addiction 2009;104:669-75.

Reported by

Roberta B. Caixeta, Adriana Blanco, Pan American Health Organization; Heba Fouad, Eastern Mediterranean Regional Office; Rula N. Khoury, European Regional Office; Dhirendra N. Sinha, Southeast Asian Regional Office; James Rarick, Western Pacific Regional Office; Edouard Tursan d'Espaignet, Douglas Bettcher, Tobacco Free Initiative, World Health Organization. GATS Collaborative Group. Sara A. Mirza, Rachel B. Kaufmann, Linda J. Andes, Glenda Blutcher-Nelson, Jason Hsia, Samira Asma, Terry Pechacek, Office on Smoking and Health, CDC. Corresponding contributor: Sara A. Mirza, CDC, smirza@cdc.gov, 770-488-6389.

* Additional information and GATS country reports are available at http://www. cdc.gov/tobacco/global/gats.

([dagger]) Respondents who reported currently smoking manufactured (i.e., commercial) cigarettes on a "daily" or "less than daily" basis. The term "smokers" in this report refers to current smokers of manufactured cigarettes. Smokers of other tobacco products, such as bidis, kreteks, hand-rolled cigarettes, cigars, pipes, and waterpipes who did not also smoke manufactured cigarettes are not included in this analysis.

([section]) "In the last 30 days, did you notice any health warnings on cigarette packages and "In the last 30 days, have warning labels on cigarette packages led you to think about quitting?"

([paragraph]) Pictorial health warning labels currently in use are available at http://www.who. int/tobacco/healthwarningsdatabase/en/index.html.

** A "best buy" is an intervention that is not only highly cost-effective but also inexpensive, feasible, and culturally acceptable to implement.
TABLE 1. Characteristics of health warning labels on cigarette
packages--Global Adult Tobacco Survey (GATS), 14 countries, 2008-2010

                           Warnings     Warning      Warning
              Year(s)      appear on    describes    label is in
              survey       each         harmful      principal
Country       conducted    package      effects      language(s)

Bangladesh    2009         Yes          Yes          Yes
Brazil        2008         Yes          Yes          Yes
China         2010         Yes          Yes          Yes/No *
Egypt         2009         Yes          Yes          Yes
India         2009-2010    Yes          Yes          Yes
Mexico        2009         Yes          No           Yes
Philippines   2009         Yes          Yes          Yes
Poland        2009-2010    Yes          Yes          Yes
Russia        2009         Yes          Yes          Yes
Thailand      2009         Yes          Yes          Yes
Turkey        2008         Yes          Yes          Yes
Ukraine       2010         Yes          Yes          Yes
Uruguay       2009         Yes          Yes          Yes
Vietnam       2010         Yes          Yes          Yes

                                                           Rotating
                           Law            Percentage       warnings/
              Law          mandates       of front/back    number of
              mandates     font style,    covered by       warnings
              specific     size and       health           approved
Country       warnings     color          warning          by law

Bangladesh    Yes          Yes            30/30            Yes/6
Brazil        Yes          Yes            0/100            Yes/10
China         Yes          Yes            30/30            Yes/2
Egypt         Yes          Yes            50/50            Yes/4
India         Yes          Yes            40/0             Yes/2
Mexico        No           No             30/100           No
Philippines   Yes          No             30/0             Yes/4
Poland        Yes          Yes            30/40            Yes/16
Russia        Yes          Yes            4/4              Yes/2
Thailand      Yes          Yes            50/50            Yes/9
Turkey        Yes          Yes            30/40            Yes/16
Ukraine       Yes          Yes            30/30            Yes/7
Uruguay       Yes          Yes            50/50            Yes/6
Vietnam       Yes          Yes            30/30            Yes/2

              Warnings
              include a
              picture or
Country       pictogram

Bangladesh    No
Brazil        Yes
China         No
Egypt         Yes
India         Yes/No ([dagger])
Mexico        No
Philippines   No
Poland        No
Russia        No
Thailand      Yes
Turkey        No
Ukraine       No
Uruguay       Yes
Vietnam       No

Sources: Pan American Health Organization. Tobacco control
report for the Region of the Americas. Washington, DC: World
Health Organization, Pan American Health Organization; 2011.
Available at http://new.paho.org/hq/index.php?option=com_
content&task=view&id=4457&Itemid=1231&lang=en.

World Health Organization. WHO report on the global tobacco
epidemic, 2009: implementing smoke free environments.
Appendix V: country profiles. Geneva, Switzerland: World
Health Organization. Available at http://www.who.
int/tobacco/mpower/2009/Appendix_V-table_1.pdf.

* China's warning is in Mandarin on the front and in English
on the back.

([dagger]) India mandated pictorial warnings on packages
sold after May 31, 2009, but older packages still were in
circulation when GATS was conducted.

TABLE 2. Percentage of current smokers of manufactured
cigarettes aged >15 years who noticed health warning labels
on cigarette packages and percentage who, as a result, were
thinking about quitting smoking, by selected
characteristics--Global Adult Tobacco Survey (GATS), 14
countries, 2008-2010 *

                                           Bangladesh

                                    Men                  Women
                                  (4,468)               (5,161)
                                 ([dagger])

Characteristic                %       (95% CI)       %       (95% CI)

% current manufactured
  cigarette smokers         28.3    (26.3-30.4)     0.2      (0.1-0.4)
% who noticed health        91.3    (89.1-93.1)      DS             DS
  warning labels
  in past 30 days
Age group (yrs)
  15-24                     93.4    (85.9-97.0)      DS             DS
  25-64                     92.0    (89.8-93.7)      DS             DS
  [less than or
    equal to] 65            69.2    (50.4-83.2)      NR             NR
Education
  No formal education/
    Less than primary       85.3    (81.5-88.4)      DS             DS
  Completed primary/
    Less than secondary     98.3    (96.6-99.2)      DS             DS
  Completed secondary/
    Completed high school   99.3    (97.0-99.8)      NR             NR
  Completed college/
    university or above     95.7    (88.7-98.4)      NR             NR
% thinking about quitting   74.1    (69.9-77.9)      DS             DS
  smoking among those who
  noticed warning
Age group (yrs)
  15-24                     71.3    (60.4-80.2)      DS             DS
  25-64                     75.0    (70.7-78.8)      DS             DS
  >65                       71.6    (52.0-85.4)      NR             NR
Education
  No formal education/
    Less than primary       75.9    (70.8-80.3)      DS             DS
  Completed primary/
    Less than secondary     72.8    (65.9-78.8)      DS             DS
  Completed secondary/
    Completed high school   72.9    (61.4-82.0)      NR             NR
  Completed college/
    university or above     66.9    (49.5-80.6)      NR             NR

                                              Brazil

                                   Men                    Women
                                 (18,039)               (21,386)

Characteristic                %       (95% CI)       %       (95% CI)

% current manufactured
  cigarette smokers         17.7    (17.0-18.4)    11.1    (10.6-11.7)
% who noticed health        92.4    (91.2-93.5)    91.8    (90.4-93.0)
  warning labels
  in past 30 days
Age group (yrs)
  15-24                     92.5    (89.0-95.0)    93.4    (88.7-96.2)
  25-64                     93.3    (92.0-94.3)    92.2    (90.7-93.5)
  [less than or
    equal to] 65            81.5    (74.4-87.0)    82.1    (73.8-88.3)
Education
  No formal education/
    Less than primary         NA             NA      NA             NA
  Completed primary/
    Less than secondary       NA             NA      NA             NA
  Completed secondary/
    Completed high school     NA             NA      NA             NA
  Completed college/
    university or above       NA             NA      NA             NA
% thinking about quitting   71.8    (69.8-73.8)    76.6    (74.2-78.8)
  smoking among those who
  noticed warning
Age group (yrs)
  15-24                     73.5    (68.6-77.8)    74.9    (67.6-81.0)
  25-64                     71.7    (69.4-74.0)    77.1    (74.5-79.5)
  >65                       67.5    (58.3-75.5)    71.8    (62.1-79.8)
Education
  No formal education/
    Less than primary         NA             NA      NA             NA
  Completed primary/
    Less than secondary       NA             NA      NA             NA
  Completed secondary/
    Completed high school     NA             NA      NA             NA
  Completed college/
    university or above       NA             NA      NA             NA

                                              China

                                   Men                  Women
                                 (6,603)               (6,751)

Characteristic                %       (95% CI)       %       (95% CI)

% current manufactured
  cigarette smokers         50.5    (48.2-52.8)     1.9      (1.5-2.6)
% who noticed health        90.3    (85.2-93.8)    60.1    (44.4-73.9)
  warning labels
  in past 30 days
Age group (yrs)
  15-24                     91.3    (73.3-97.5)      DS             DS
  25-64                     91.6    (87.2-94.6)    61.7    (44.6-76.3)
  [less than or
    equal to] 65            69.8    (57.2-79.9)    45.9    (27.5-65.4)
Education
  No formal education/
    Less than primary       65.4    (56.9-73.0)    30.6    (17.9-47.3)
  Completed primary/
    Less than secondary     88.8    (84.6-92.0)    69.6    (48.7-84.6)
  Completed secondary/
    Completed high school   92.9    (85.2-96.7)    77.5    (42.0-94.2)
  Completed college/
    university or above     98.1    (94.9-99.3)      DS             DS
% thinking about quitting   36.5    (31.3-42.0)    42.5    (32.0-53.6)
  smoking among those who
  noticed warning
Age group (yrs)
  15-24                     37.6    (25.3-51.7)      DS             DS
  25-64                     36.2    (31.5-41.1)    37.6    (26.5-50.1)
  >65                       37.9    (29.5-47.0)      DS             DS
Education
  No formal education/
    Less than primary       35.4    (27.2-44.6)      DS             DS
  Completed primary/
    Less than secondary     42.7    (35.0-50.7)      DS             DS
  Completed secondary/
    Completed high school   36.4    (30.2-43.1)    41.1    (25.2-59.2)
  Completed college/
    university or above     27.7    (20.9-35.8)      DS             DS

                                                Egypt

                                   Men                    Women
                                 (10,062)               (10,862)
                                 ([dagger])

Characteristic                %       (95% CI)       %       (95% CI)

% current manufactured
  cigarette smokers         31.7    (30.5-33.0)     0.2      (0.1-0.4)
% who noticed health        98.6    (97.9-99.0)      DS             DS
  warning labels
  in past 30 days
Age group (yrs)
  15-24                     98.4    (95.4-99.4)      DS             DS
  25-64                     98.7    (98.0-99.1)      DS             DS
  [less than or
    equal to] 65            98.1    (94.5-99.3)      NR             NR
Education
  No formal education/
    Less than primary       98.5    (97.1-99.2)      DS             DS
  Completed primary/
    Less than secondary     98.3    (95.1-99.4)      DS             DS
  Completed secondary/
    Completed high school   98.6    (97.6-99.2)      DS             DS
  Completed college/
    university or above     99.1    (97.6-99.6)      DS             DS
% thinking about quitting   45.1    (42.7-47.5)      DS             DS
  smoking among those who
  noticed warning
Age group (yrs)
  15-24                     44.6    (38.0-51.4)      DS             DS
  25-64                     45.9    (43.2-48.5)      DS             DS
  >65                       35.3    (27.3-44.3)      NR             NR
Education
  No formal education/
    Less than primary       44.8    (40.6-49.0)      DS             DS
  Completed primary/
    Less than secondary     43.6    (36.8-50.6)      DS             DS
  Completed secondary/
    Completed high school   47.7    (44.2-51.2)      DS             DS
  Completed college/
    university or above     37.2    (31.1-43.8)      DS             DS

                                             India

                                   Men                    Women
                                 (33,767)               (35,529)

Characteristic                %       (95% CI)       %       (95% CI)

% current manufactured
  cigarette smokers          9.6     (9.0-10.3)     0.5      (0.4-0.7)
% who noticed health        78.4    (75.9-80.7)    18.9    (12.0-28.4)
  warning labels
  in past 30 days
Age group (yrs)
  15-24                     81.2    (75.2-86.0)    36.9     (9.4-76.7)
  25-64                     78.2    (75.4-80.8)    21.1    (12.8-32.9)
  [less than or
    equal to] 65            68.2    (57.2-77.5)     8.3     (3.2-19.8)
Education
  No formal education/
    Less than primary       65.4    (60.3-70.1)    13.8     (8.1-22.7)
  Completed primary/
    Less than secondary     80.0    (75.8-83.5)    49.3    (21.7-77.4)
  Completed secondary/
    Completed high school   87.7    (83.5-91.0)    44.8    (13.6-80.8)
  Completed college/
    university or above     89.2    (84.7-92.5)      DS             DS
% thinking about quitting   53.7    (50.6-56.8)    76.1    (58.1-88.0)
  smoking among those who
  noticed warning
Age group (yrs)
  15-24                     68.0    (60.4-74.7)      DS             DS
  25-64                     50.3    (47.1-53.5)    72.1    (51.5-86.3)
  >65                       45.0    (33.3-57.2)      DS             DS
Education
  No formal education/
    Less than primary       52.8    (46.2-59.2)    84.2    (66.4-93.4)
  Completed primary/
    Less than secondary     53.8    (48.6-58.8)    61.1    (21.4-90.0)
  Completed secondary/
    Completed high school   56.0    (50.2-61.6)    73.6    (49.0-89.0)
  Completed college/
    university or above     51.3    (43.4-59.1)      DS             DS

                                               Mexico

                                  Men                    Women
                                 (6,160)                (7,457)

Characteristic                %       (95% CI)       %       (95% CI)

% current manufactured
  cigarette smokers         24.5    (22.8-26.2)     7.5      (6.4-8.8)
% who noticed health        83.5    (80.6-86.0)    87.6    (83.0-91.1)
  warning labels
  in past 30 days
Age group (yrs)
  15-24                     86.6    (82.1-90.1)    90.8    (79.4-96.2)
  25-64                     82.7    (79.3-85.6)    86.4    (79.6-91.2)
  [less than or
    equal to] 65            73.3    (63.3-81.4)      DS             DS
Education
  No formal education/
    Less than primary       69.2    (61.2-76.1)    64.4    (46.8-78.8)
  Completed primary/
    Less than secondary     81.2    (75.6-85.7)    82.8    (67.9-91.6)
  Completed secondary/
    Completed high school   88.6    (85.6-91.1)    91.9    (87.3-94.9)
  Completed college/
    university or above     82.0    (67.4-90.9)    93.9    (76.2-98.7)
% thinking about quitting   37.3    (33.5-41.3)    42.6    (35.8-49.7)
  smoking among those who
  noticed warning
Age group (yrs)
  15-24                     36.3    (30.3-42.7)    33.5    (22.0-47.3)
  25-64                     38.4    (33.4-43.7)    46.0    (38.6-53.7)
  >65                       27.3    (17.4-40.1)      DS             DS
Education
  No formal education/
    Less than primary       45.7    (35.7-56.0)    32.6    (19.9-48.6)
  Completed primary/
    Less than secondary     38.9    (32.0-46.3)    56.9    (44.8-68.3)
  Completed secondary/
    Completed high school   36.9    (31.9-42.1)    36.9    (29.2-45.3)
  Completed college/
    university or above     25.0    (15.4-37.8)    53.8    (32.6-73.8)

                                           Philippines

                                   Men                  Women
                                (4,740)                (4,961)
                               ([dagger])

Characteristic                %       (95% CI)       %       (95% CI)

% current manufactured         %
  cigarette smokers         46.6    (44.7-48.6)     7.5      (6.5-8.5)
% who noticed health        91.8    (89.9-93.3)    84.2    (78.8-88.4)
  warning labels
  in past 30 days
Age group (yrs)
  15-24                     93.4    (88.9-96.2)    95.9    (87.3-98.8)
  25-64                     92.0    (89.9-93.7)    86.8    (81.2-91.0)
  [less than or
    equal to] 65            76.3    (62.7-86.1)    55.9    (36.1-74.0)
Education
  No formal education/
    Less than primary       80.5    (75.2-84.8)    72.4    (62.1-80.7)
  Completed primary/
    Less than secondary     92.1    (87.5-95.0)    84.4    (66.7-93.6)
  Completed secondary/
    Completed high school   97.4    (96.0-98.3)    92.7    (84.8-96.7)
  Completed college/
    university or above     98.6    (96.6-99.4)    98.0    (92.0-99.5)
% thinking about quitting   41.7    (38.8-44.7)    44.6    (37.0-52.4)
  smoking among those who
  noticed warning
Age group (yrs)
  15-24                     44.9    (38.5-51.5)    45.6    (25.3-67.5)
  25-64                     40.7    (37.6-43.9)    44.4    (35.8-53.4)
  >65                       40.3    (27.7-54.2)    43.9    (23.0-67.1)
Education
  No formal education/
    Less than primary       35.8    (30.3-41.8)    44.8    (30.4-60.0)
  Completed primary/
    Less than secondary     37.5    (31.0-44.6)    51.8    (33.0-70.0)
  Completed secondary/
    Completed high school   45.6    (41.5-49.8)    44.5    (33.6-56.0)
  Completed college/
    university or above     46.5    (40.4-52.7)    34.1    (19.7-52.2)

                                              Poland

                                   Men                   Women
                                 (3,867)                (3,973)

Characteristic                %       (95% CI)       %       (95% CI)

% current manufactured
  cigarette smokers         35.1    (33.2-37.1)    22.9    (21.4-24.5)
% who noticed health        97.0    (95.8-97.9)    96.9    (95.4-97.9)
  warning labels
  in past 30 days
Age group (yrs)
  15-24                     95.7    (90.1-98.1)    97.6    (92.6-99.3)
  25-64                     97.4    (96.0-98.3)    96.9    (95.2-98.0)
  [less than or
    equal to] 65            96.0    (90.4-98.4)    95.3    (72.8-99.4)
Education
  No formal education/
    Less than primary         DS             DS      DS             DS
  Completed primary/
    Less than secondary     96.5    (91.9-98.5)    93.1    (84.7-97.0)
  Completed secondary/
    Completed high school   97.1    (95.6-98.0)    97.5    (95.9-98.5)
  Completed college/
    university or above     98.2    (94.3-99.4)    96.3    (90.2-98.7)
% thinking about quitting   16.1    (13.6-19.1)    21.7    (18.4-25.5)
  smoking among those who
  noticed warning
Age group (yrs)
  15-24                     12.6     (7.6-20.1)    15.4     (8.6-26.0)
  25-64                     16.2    (13.4-19.5)    22.5    (18.8-26.8)
  >65                       23.2    (14.8-34.4)    25.5    (12.9-44.1)
Education
  No formal education/
    Less than primary         DS             DS      DS             DS
  Completed primary/
    Less than secondary     26.5    (19.5-34.9)    37.9    (28.8-48.0)
  Completed secondary/
    Completed high school   15.8    (12.9-19.2)    21.0    (17.2-25.4)
  Completed college/
    university or above      7.9     (3.5-16.9)    15.6     (9.1-25.4)

                                              Russia

                                   Men                   Women
                                 (6,217)                (5,189)

Characteristic                %       (95% CI)       %       (95% CI)

% current manufactured
  cigarette smokers         59.3    (57.6-61.0)    21.4    (19.3-23.5)
% who noticed health        94.6    (93.1-95.8)    94.7    (92.1-96.5)
  warning labels
  in past 30 days
Age group (yrs)
  15-24                     95.7    (92.9-97.5)    93.5    (87.2-96.9)
  25-64                     94.7    (93.1-95.9)    95.9    (93.0-97.6)
  [less than or
    equal to] 65            90.7    (81.4-95.6)      DS             DS
Education
  No formal education/
    Less than primary         DS             DS      NR             NR
  Completed primary/
    Less than secondary     90.0    (79.7-95.4)      DS             DS
  Completed secondary/
    Completed high school   95.3    (93.7-96.5)    95.1    (92.2-96.9)
  Completed college/
    university or above     93.0    (89.3-95.5)    95.1    (91.1-97.3)
% thinking about quitting   33.6    (30.7-36.6)    33.9    (29.2-39.1)
  smoking among those who
  noticed warning
Age group (yrs)
  15-24                     37.5    (31.6-43.8)    35.6    (26.6-45.7)
  25-64                     32.5    (29.5-35.7)    33.7    (28.6-39.2)
  >65                       35.5    (26.9-45.1)      DS             DS
Education
  No formal education/
    Less than primary         DS             DS      NR             NR
  Completed primary/
    Less than secondary     35.7    (22.7-51.2)      DS             DS
  Completed secondary/
    Completed high school   34.7    (31.5-37.9)    38.2    (33.1-43.6)
  Completed college/
    university or above     30.1    (25.4-35.1)    26.9    (18.7-37.2)

                                            Thailand

                                   Men                  Women
                                 (10,052)              (10,514)
                                ([dagger])

Characteristic                %       (95% CI)       %       (95% CI)

% current manufactured
  cigarette smokers         29.6    (28.1-31.1)     1.1      (0.9-1.4)
% who noticed health        99.2    (98.8-99.5)    98.0    (95.2-99.2)
  warning labels
  in past 30 days
Age group (yrs)
  15-24                     99.8    (99.2-100.0)     DS             DS
  25-64                     99.1    (98.6-99.4)    99.2    (96.5-99.8)
  [less than or
    equal to] 65            96.5    (89.9-98.8)      DS             DS
Education
  No formal education/
    Less than primary       98.2    (96.8-99.0)    97.1    (88.8-99.3)
  Completed primary/
    Less than secondary     99.3    (98.3-99.7)    97.1    (88.1-99.4)
  Completed secondary/
    Completed high school   99.6    (99.1-99.8)    99.1    (93.8-99.9)
  Completed college/
    university or above     98.7    (94.3-99.7)      DS             DS
% thinking about quitting   71.4    (68.1-74.5)    66.1    (56.5-74.6)
  smoking among those who
  noticed warning
Age group (yrs)
  15-24                     69.4    (60.5-77.0)      DS             DS
  25-64                     72.5    (69.3-75.4)    70.5    (60.6-78.7)
  >65                       59.5    (48.4-69.7)      DS             DS
Education
  No formal education/
    Less than primary       72.3    (66.9-77.1)    77.6    (64.9-86.6)
  Completed primary/
    Less than secondary     73.8    (68.1-78.8)    81.5    (66.2-90.9)
  Completed secondary/
    Completed high school   70.7    (66.0-75.0)    53.4    (36.2-69.9)
  Completed college/
    university or above     63.9    (54.9-72.0)      DS             DS

                                             Turkey

                                   Men                   Women
                                 (4,269)                (4,761)

Characteristic                %       (95% CI)       %       (95% CI)

% current manufactured
  cigarette smokers         45.8    (43.7-17.9)    14.9    (13.8-16.2)
% who noticed health        95.3    (93.6-96.6)    94.3    (91.0-96.4)
  warning labels
  in past 30 days
Age group (yrs)
  15-24                     93.9    (88.9-96.7)    96.0    (87.9-98.7)
  25-64                     95.9    (94.1-97.2)    94.0    (90.1-96.4)
  [less than or
    equal to] 65            89.2    (78.9-94.9)      DS             DS
Education
  No formal education/
    Less than primary       90.9    (82.9-95.3)    71.5    (55.1-83.7)
  Completed primary/
    Less than secondary     95.1    (92.9-96.7)    98.7    (96.6-99.5)
  Completed secondary/
    Completed high school   96.7    (94.0-98.2)    95.5    (89.4-98.2)
  Completed college/
    university or above     93.8    (85.6-97.5)    96.3    (88.6-98.9)
% thinking about quitting   48.8    (45.5-52.1)    49.5    (45.0-54.1)
  smoking among those who
  noticed warning
Age group (yrs)
  15-24                     42.5    (34.7-50.7)    52.2    (39.8-64.3)
  25-64                     50.1    (46.5-53.7)    49.4    (44.3-54.4)
  >65                       53.1    (39.7-66.0)      DS             DS
Education
  No formal education/
    Less than primary       46.5    (35.0-58.5)    54.1    (39.7-67.8)
  Completed primary/
    Less than secondary     53.3    (49.1-57.5)    52.7    (46.3-59.1)
  Completed secondary/
    Completed high school   44.5    (39.4-49.6)    49.6    (42.6-56.7)
  Completed college/
    university or above     41.7    (33.3-50.7)    28.8    (18.6-41.8)

                                             Ukraine

                                   Men                   Women
                                 (4,076)                (4,082)

Characteristic                %       (95% CI)       %       (95% CI)

% current manufactured
  cigarette smokers         49.5    (47.5-51.4)    11.1     (9.8-12.5)
% who noticed health        96.6    (95.3-97.5)    96.8    (91.6-98.8)
  warning labels
  in past 30 days
Age group (yrs)
  15-24                     98.5    (96.2-99.4)    92.5    (65.5-98.8)
  25-64                     96.6    (95.2-97.6)    98.0    (95.6-99.1)
  [less than or
    equal to] 65            90.9    (85.2-94.6)      NR             NR
Education
  No formal education/
    Less than primary         DS             DS      DS             DS
  Completed primary/
    Less than secondary     89.4    (80.9-94.4)      DS             DS
  Completed secondary/
    Completed high school   96.8    (95.5-97.7)    98.0    (95.3-99.2)
  Completed college/
    university or above     98.4    (95.4-99.4)    98.8    (94.7-99.7)
% thinking about quitting   58.9    (55.2-62.5)    63.9    (57.4-69.9)
  smoking among those who
  noticed warning
Age group (yrs)
  15-24                     56.3    (47.1-65.0)    51.0    (32.8-68.9)
  25-64                     59.8    (56.1-63.3)    67.3    (61.0-73.1)
  >65                       55.7    (46.2-64.8)      NR             NR
Education
  No formal education/
    Less than primary         DS             DS      DS             DS
  Completed primary/
    Less than secondary     50.6    (37.8-63.3)      DS             DS
  Completed secondary/
    Completed high school   59.4    (55.8-63.0)    62.6    (55.1-69.5)
  Completed college/
    university or above     58.8    (49.6-67.4)    72.9    (62.2-81.4)

                                             Uruguay

                                   Men                   Women
                                 (2,634)                (2,947)
                                ([dagger])

Characteristic                %       (95% CI)       %       (95% CI)

% current manufactured
  cigarette smokers         24.3    (22.0-26.7)    18.6    (16.9-20.4)
% who noticed health        97.1    (94.5-98.5)    97.2    (94.3-98.6)
  warning labels
  in past 30 days
Age group (yrs)
  15-24                     98.1    (87.4-99.7)    98.0    (92.2-99.5)
  25-64                     97.6    (94.6-99.0)    97.2    (93.3-98.8)
  [less than or
    equal to] 65            80.9    (52.1-94.3)    94.4    (82.4-98.4)
Education
  No formal education/
    Less than primary       87.3    (72.6-94.7)    90.9    (75.3-97.0)
  Completed primary/
    Less than secondary     96.2    (90.0-98.6)    98.3    (95.6-99.3)
  Completed secondary/
    Completed high school   99.4    (96.7-99.9)    97.0    (91.0-99.0)
  Completed college/
    university or above     100.0   (88.7-100.0)   99.1    (93.7-99.9)
% thinking about quitting   39.3    (33.6-45.4)    47.9    (42.6-53.3)
  smoking among those who
  noticed warning
Age group (yrs)
  15-24                     50.1    (37.9-62.2)    60.2    (46.3-72.7)
  25-64                     36.8    (30.7-43.2)    45.0    (38.9-51.1)
  >65                       13.9     (5.1-32.5)    45.8    (28.4-64.2)
Education
  No formal education/
    Less than primary       46.7    (29.2-64.9)    68.7    (47.5-84.1)
  Completed primary/
    Less than secondary     44.5    (35.4-54.0)    63.9    (54.4-72.4)
  Completed secondary/
    Completed high school   33.9    (26.2-42.5)    37.3    (30.8-44.3)
  Completed college/
    university or above     37.3    (22.0-55.6)    33.3    (20.5-49.1)

                                             Vietnam

                                 Men                    Women
                               (4,356)                 (5,569)

Characteristic                %       (95% CI)       %       (95% CI)

% current manufactured
  cigarette smokers         39.1    (37.0-41.2)     1.0      (0.6-1.5)
% who noticed health        96.1    (94.8-97.1)    75.0    (53.4-88.7)
  warning labels
  in past 30 days
Age group (yrs)
  15-24                     97.7    (94.3-99.1)      DS             DS
  25-64                     95.9    (94.3-97.0)    76.7    (54.2-90.1)
  [less than or
    equal to] 65            95.2    (86.4-98.4)      DS             DS
Education
  No formal education/
    Less than primary       89.9    (84.7-93.5)    70.9    (49.9-85.6)
  Completed primary/
    Less than secondary     96.7    (94.4-98.0)      DS             DS
  Completed secondary/
    Completed high school   98.0    (96.6-98.9)      DS             DS
  Completed college/
    university or above     99.1    (96.2-99.8)      DS             DS
% thinking about quitting   73.1    (70.3-75.8)    61.1    (42.1-77.2)
  smoking among those who
  noticed warning
Age group (yrs)
  15-24                     72.1    (63.3-79.6)      DS             DS
  25-64                     73.5    (70.5-76.3)    68.0    (48.2-82.9)
  >65                       70.0    (59.5-78.8)      DS             DS
Education
  No formal education/
    Less than primary       66.5    (59.8-72.6)    48.1    (27.5-69.2)
  Completed primary/
    Less than secondary     72.9    (67.4-77.7)      DS             DS
  Completed secondary/
    Completed high school   75.7    (71.8-79.3)      DS             DS
  Completed college/
    university or above     74.0    (66.7-80.2)      DS             DS

Abbreviations: CI = confidence interval; DS = data suppressed
because cell size <30; NR = no reported cases; NA = Not applicable
(GATS countries have varying educational systems. Based on the
questionnaire categories used in each country, four approximately
comparable categories of education were created. However, Brazil's
educational categories could not be coded in this fashion).

* Results presented in this report differ from those presented in
previously published GATS fact sheets or country reports (available
at http://www.cdc.gov/tobacco/global) because of differing age
and education category breakdowns and because this report includes
only respondents who reported being current smokers of manufactured
cigarettes. Also, in this report, the percentage who thought about
quitting was calculated only among those who noticed labels.

([dagger]) Number sampled.
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Article Details
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Author:Caixeta, Roberta B.; Blanco, Adriana; Fouad, Heba; Khoury, Rula N.; Sinha, Dhirendra N.; Rarick, Jam
Publication:Morbidity and Mortality Weekly Report
Geographic Code:1USA
Date:May 27, 2011
Words:6442
Previous Article:World No Tobacco Day--May 31, 2011.
Next Article:Human Jamestown Canyon virus infection--Montana, 2009.
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