INTRODUCTION

In 2004, Nigeria signed the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC). Nigeria subsequently ratified the Protocol in 2005¹. Article 11 of the World Health Organization FCTC makes provisions for the packaging and labelling of tobacco products. However, the tobacco industry continues to use cigarette packs to retain consumers and attract new ones¹. This phenomenon is more pronounced in parts of developing countries where enforcements are relatively weak, and the industry focuses its subtle marketing². Research has shown that health warnings on cigarette brands aid in quitting, decrease initiation attempts, and reduce the appeal to younger people². Nigeria introduced the implementation of compliance with specified standards for cigarette packaging in 2017, following the National Tobacco Control Act, signed into law in 2015³. The tobacco industry, as such, is responsible for altering its products’ packaging to meet the current national and WHO FCTC standards.

Health Warning Labels (HWLs) are an important component of any comprehensive tobacco control program. The effectiveness of HWLs on tobacco packs is well documented: they increase knowledge of the harms of tobacco^4,5, increase intentions to quit and quit attempts among smokers^6-10, prevent relapse in former smokers^8,11, and prevent youth smoking initiation, although some studies show mixed results¹². In comparison to text-only warnings, pictorial warnings are also more likely to be noticed^5,6,10,13,14, more effective in educating the public about the dangers of smoking^13-15, and increase quit intention^{5,10,13,15-17}.

Globally, there are variations in tobacco packaging and labelling requirements by country. At least 53 countries now require pictorial HWLs that cover 30% of the principal display areas of a pack¹⁸. Australia has implemented plain packaging with health warnings that cover 75% of the front of the pack and 90% of the back¹⁸. Nepal implemented pictorial warnings that cover 90% of the front and back of the pack¹⁸. Some Parties to the FCTC only meet minimal requirements – for 2011. Also, compliance with this varies across different tobacco product brands and within and between countries². It is especially important to investigate compliance with country HWL requirements as tobacco companies are responsible for complying with HWL policies, unlike legislation regarding smoke-free places which is the responsibility of facility owners. Non-compliance with HWL best practices can result in poorer knowledge about the dangers of tobacco use, reduced quitting behaviors, and increased smoking initiation. Given that compliance with HWL practices is key to achieving the ultimate health goals of policy interventions, our research aimed to examine compliance with HWL requirements in Nigeria. While many countries have been able to monitor compliance with warning labels and packaging over time, Nigeria is yet to have such a review, hence the present study. This study aims to review the status of cigarette warning label compliance in three of the most populated cities in Nigeria across different neighborhoods (low-, middle- and high-income), using the Johns Hopkins School of Public Health (JHSPH) TPackSS methodology. The study also aims to describe pack design features that may violate the packaging laws in Nigeria. The study results will provide valuable compliance information, an assessment of the current disparities, and offer evidence-based recommendations for moving forward.

METHODS

We used a systematic protocol to collect packs and code HWLs¹⁹. Cigarette packs were purchased between December 2019 and January 2020. According to the TPackSS methods, to maximize the diversity of the sample of packs, we chose the most populous city and two other cities from the top 10 populous cities in Nigeria (considering geographical location, ethnicity, and religion). In all, 12 neighborhoods were selected from each of the three cities, for a total of 36 neighborhoods in the country of Nigeria. We deployed a mix of local and national sources, including census data, to create a sampling frame of high-, middle- and low-SES areas for each city. The 12 neighborhoods equally represented high-, middle-, and low-SES neighborhoods, 4 of each per city sampled. The Protocol required purchasing unique packs in one store in each of the 36 neighborhoods per country (fully described in the protocol paper for the study). At the first store in the first city, one of every unique cigarette pack was purchased. In each subsequent neighborhood, we purchased any unique packs that we had not yet purchased. In total, we purchased 90 unique packs.

All of the 90 cigarette packs purchased had an HWL. To assess the compliance of each cigarette pack’s HWL with country requirements, we adapted a codebook based on Nigeria’s requirements regarding cigarette HWLs online from (http://globaltobaccocontrol.org/tpackss/resources).

We also reviewed FCTC Article 11 Guidelines²⁰ and compared countries’ requirements for HWLs with those required and recommended by the FCTC implementation guidelines. Terms such as each Party ‘shall adopt/shall require’ or ‘should mandate/should address’ or ‘should prohibit/should prevent’ were interpreted as a requirement, whereas ‘should consider’ was interpreted as a recommendation. We looked at requirements and recommendations for health warning label location, size, use of pictorials and color, message content, language, and banning of misleading descriptors. For Nigeria, the requirements for the HWLs are: 1) for them to be in rotation, large, clear, visible, and legible; 2) should be ≥50% of the principal display areas but shall be ≥30% of the principal display areas; and 3) may be in the form of or include pictures or pictograms.

Global Adult Tobacco Survey (GATS) and Euromonitor country-level data were assessed in advance to identify the type of vendors where consumers purchase tobacco packs. Cigarette sales in Nigeria are mainly via the following channels: kiosks, street vendors, supermarkets, hotels, restaurants, and bars/clubs⁴. These four types of tobacco vendors were purposively selected based on their consumer purchasing and product distribution ranking among vendor types in the country. In the three cities, the first vendor visited was selected from a middle socioeconomic status (SES) neighborhood. Within each neighborhood, data collectors identified a ‘hub’ (transit center, major shopping center, source of commerce, etc.) where they first travelled to. Data collectors followed the TPackSS vendor selection and walking protocol. In the case that unique packs were not found at the first vendor, data collectors visited up to four vendors in each neighborhood until at least one unique pack was found. The neighborhoods visited in the three states in Nigeria are shown in Supplementary file Table 1.

Two coders used the codebook to independently code each pack that had an HWL in the current rotation from the city in which the pack was purchased (n=90) for health warning compliance. Any discrepancies between coders were resolved by a third coder. Our team measured packs with standardized rulers, and we rounded-off measurements to the nearest millimeter (mm). We had mostly the exact measurements, a difference of 1 mm was averaged for discrepancies, and when higher, we involved a third reviewer. Quality checks were also done to ensure the accuracy of entered data, especially the measurements.

We applied up to four common indicators for HWL compliance that were relevant for Nigeria based on in-country regulations: 1) health warning location (top, bottom, front, and/or back); 2) health warning size (percent coverage); 3) health warning elements (e.g. text color, background color, borders); and 4) health warning text size. We assessed compliance with each applicable indicator. We also determined a summary measure of compliance: an HWL was determined to be compliant overall if it was compliant with all applicable indicator measures. To estimate the level of inter-rater reliability for the binary variables, we assessed percent agreement as well as the prevalence-adjusted and bias-adjusted kappa (PABAK) statistic to account for the low prevalence of our binary outcomes^21-23. For the continuous variables, including height and width of the pack and warning label area, and height of warning text, to the millimeter (mm), we used percent agreement²⁴. We used descriptive statistics to examine the nature and extent of HWL compliance.

We assessed compliance by SES of the neighborhood, pack shape, stick count, parent company (three major transnational parent companies), and brand family (the five brands with the highest frequency in our sample). All analyses were conducted using Microsoft Excel. To determine if there was bias introduced into our compliance estimates due to the Protocol that required a large purchase at the first store – which often occurred in a high SES neighborhood – we used Pearson’s chi-squared tests to assess statistically significant differences.

RESULTS

DISCUSSION

Our findings suggest that cigarette manufacturers are often not fulfilling all their obligations regarding HWLs on cigarette packs. Compliance with HWL requirements varied across cities. That compliance varies by city may be due in part to the country’s ability to enforce its laws more generally or the level of tobacco industry interference in a country. There was high compliance for the location of the warning, but, overall, few of the HWLs on the cigarette met Nigeria’s size requirements. This is concerning, especially given the preponderance of the evidence that HWLs are more effective when they are bigger¹⁶. Compliance was not different for packs purchased in the first store compared to packs purchased in all other stores in the country. This suggests that the estimates of compliance were not influenced by choice of the index store. Further, overall compliance varied by parent company and brand family. Few packs manufactured by KT&G were compliant, but even BAT – which had the overall highest compliance – produced packs that were not fully compliant. While some of these non-compliant packs may be counterfeit, it is up to the manufacturers to protect their brands.

Countries need to monitor regularly whether manufacturers are adhering to HWL requirements and hold manufacturers accountable when they do not. While HWLs must comply with their country’s requirements to maximize the public health impacts of HWLs, high compliance with policies that involve inadequate requirements is also a key issue to be addressed. At minimum, Nigeria should enforce compliance with in-country requirements and strengthen a surveillance system for tobacco products. Moving to higher coverage and pictorial warnings would also better inform people in Nigeria about the danger of tobacco products.

CONCLUSIONS

The analysis of the packs showed various levels of compliance with Health Warning Label provisions for Nigeria. Periodic evaluations are required to ensure that minimum requirements are met.