Rahmat Awang , Maizurah Omar (Clearinghouse for Tobacco Control, USM, Penang)

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

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

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

4. What CMTM reported?

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

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

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

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

10. Current Graphic Health Warning Labels

11. Duck to verify the security ink

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

13. Characteristics of respondents who sent and not sent the packs weighted data. a mean, sd- standard deviation

14. Characteristics of respondents who sent and not sent the packs cont... weighted data

15. Relationship between characteristics of respondents and pack sent or not sent Reported OR and 95% CI were from multiple logistic regression. NS Not significant, *p<0.05, **p<0.01, ***p<0.001 n- number of respondents in univariate analysis.

16. Relationship between characteristics of respondents and packs sent or not sent cont... Reported OR and 95% CI were from multiple logistic regression. NS Not significant, *p<0.05, **p<0.01, ***p<0.001 Significant age*State interaction present (P<0.001). a p value independent sample T-Test. n-number of respondents in univariate analysis

17. Percentage of ILLICIT packs received (N=685)

18. Typesof popular cigarettes packs identified as ILLICIT Total brands as illicit = 16

19. ILLICIT cigarette packages received based on check list

20. Characteristics of respondents who sent illicit or genuine packs *weightage data

21. Characteristics of respondents who sent illicit or genuine packs (cont...) *weightage data

22. Relationship between characteristics of respondents and received ILLICIT or genuine packs Weighted data. n- number of respondents in univariate analysis. Reported OR and 95% CI were from univariate & multiple logistic regression. NS Not significant, *p<0.05, **p<0.01, ***p<0.001

23. Relationship between characteristics of respondents and received ILLICIT or genuine packs Weighted data. n- number of respondents in univariate analysis. Reported OR and 95% CI were from univariate . NS Not significant, *p<0.05, **p<0.01, ***p<0.001. a p value independent sample T Test

24. Places where ILLICIT packs were bought (N=139)

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

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

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

28. Thank You