Tobacco control in Macao: a quantitative analysis on the implementation of WHO MPOWER measures

Wai-seng Kuok 郭偉誠, Wai-leng Lam 林惠玲, Edmundo PL Lao 劉百球, Mei-kun Lok 陸美娟, Iek-long Lo 羅奕龍

HK Pract 2023;45:45-50

Summary

Objective: To quantify the implementation of MPOWER measures in Macao after a decade of legislation and to compare current MPOWER performance with countries in Western Pacific.
Design: Retrospective descriptive study.
Subjects: The status of tobacco control and policy in Macao.
Main outcome Measures: The changes of MPOWER scores and prevalence of tobacco use in Macao were studied.
Results: The MPOWER scores reflected a great progress from 18 to 34 in the 10 years after legislation. The prevalence of tobacco and related products use in population >=15 years of age, from 2011 to 2022, has declined from 16.9% to 11.1%. The prevalence of tobacco use in teenage population between 13-15 years of age, from 2010 to 2021, has declined from 9.5% to 3.8%. For the MPOWER score, Macao ranks on the front position in Western Pacific for tobacco control.
Conclusions: After ten years’ implementation of the MPOWER measures and legislation, Macao has achieved a greater improvement with her tobacco control, which compares favourably with other Western Pacific countries. Macao has reached the target for reducing tobacco use as suggested by the World Health Organization (WHO) and the prevalence of tobacco use in Macao remains low.

Keywords: Tobacco control; WHO MPOWER measures; Legislation

摘要

目的： 以量化方式探討澳門在訂立控煙法十年後MPOWER 控煙措施的執行，並與目前西太平洋地區作比較。
設計： 回顧性描述性研究。
對象： 澳門的控煙政策現狀。
主要結果測量： 研究了澳門的MPOWER評分及煙草使用率 的改變。
研究結果： 澳門在立法10年後，MPOWER評分從18上升到 34，反映了控煙措施的明顯改善。從2011年到2022年，澳 門15歲以上人口的煙草及相關產品使用率由16.9%下降至 11.1%。從2010年到2021年，13-15歲青少年人口的煙草使用 率從9.5%下降到3.8%。根據MPOWER評分，澳門在控煙執 行方面位居西太平洋地區前列。
結論： 經過十年的MPOWER措施執行和立法，澳門在控 煙方面取得了很大進步，與其他西太平洋國家地區相比毫 不遜色。澳門已達到世界衛生組織建議減少煙草使用的目 標，且目前澳門的煙草使用率仍處於低水平。

關鍵詞： 煙草控制，世界衛生組織 MPOWER 措施，立法

Introduction

Tobacco use is a worldwide public health issue. According to the WHO, in 2020, 22.3% of the global population used tobacco. Tobacco is the single largest preventable cause of death worldwide. There are more than 8 million deaths a year related to tobacco use, including around 1.2 million deaths from exposure to second-hand smoking.¹ The World Health Organization Framework Convention on Tobacco Control (WHO FCTC) is an international agreement that came into force in response to the global tobacco epidemic.² The treaty entered into force on 27th February 2005. In 2008, in order to assist the implementation of the WHO FCTC in party countries, WHO introduced a package of 6 measures under the acronym of “MPOWER” to reduce tobacco use: (M) monitor tobacco use and prevention policies, (P) protect people from tobacco smoke, (O) offering help to quit tobacco use, (W) warn about the dangers of tobacco, (E) enforce bans on tobacco advertising, promotion and sponsorship, and (R) raise taxes on tobacco.³ These measures include a set of policies with proven effectiveness in reducing smoking and to provide guidelines for tobacco control in numerous countries and regions.⁴

China became a party country of the WHO Framework Convention on Tobacco Control on 9th January 2006. Macao Special Administrative Region, as a part of China, is bound by China’s ratification of the treaty. To consistently implement the FCTC and to effectively control the tobacco consumption, Macao put into law “The Regime of Tobacco Prevention and Control” in 2011 and has been in force since 1st January 2012. There are amendments of law in 2017 so as to perfect the tobacco control policies and came into force since 1st January 2018.

Several scoring systems have been developed to monitor the implementation of MPOWER strategy and to evaluate the effectiveness of tobacco control policies. The first such assessment was conducted by Joossens et al. in European countries in 2006. Then Heydari et al. designed the MPOWER scoring system and conducted in Eastern Mediterranean countries in 2012 based on 2011 WHO MPOWER report.⁵ The objective of this study is to quantify the implementation of MPOWER tobacco control policies on the prevalence of tobacco use in Macao after a decade of legislation and to compare the current MPOWER implementation with other nearby countries and regions in Western Pacific.

Methods

The study was conducted to quantify the implementation of MPOWER measures over the ten years’ period from 2011 to 2021 in Macao using the MPOWER score.⁵ Information was collected from Tobacco Prevention and Control Office of Macao for the year 2011 and 2021, representing data before and after legislation. The assessment was based on the checklist designed by Heydari et al. and the international tobacco control specialists in their study on tobacco control.⁵ This MPOWER scoring checklist was adopted by WHO to quantify MPOWER implementation.

The MPOWER scoring checklist includes 10 questions. There are 7 questions with 5 options scoring from 0 to 4 points, and 3 questions scoring with 4 options scoring from 0 to 3 points. Each point, for which data was not available, would be scored as 0. The total possible score was 37 (7x4 + 3x3). The checklist, together with the scoring and scale, is shown in Table 1.⁵

The data related to the prevalence of tobacco use and the current MPOWER implementation in Macao was collected from Tobacco Prevention and Control Office of Macau. The data for the current MPOWER implementation in countries of Western Pacific was collected from WHO report on the global tobacco epidemic, 2021.⁶

Results

Macao has adopted the MPOWER measures and shown continuous progress. The MPOWER scores reflected a great progress from 18 to 34 in the 10 years after legislation (Table 2). Overall, the current progress in the MPOWER implementation contributed to the prevalence decline in smoking. The prevalence of tobacco and related products use in population >=15 years of age in Macao, according to data from Tobacco Prevention and Control Office from 2011 to 2022, has declined from 16.9% to 11.1% (in male from 31.4% to 21.5%, in female from 3.8% to 2.2%), which remains on a low prevalence. The prevalence of tobacco use in teenage population between 13-15 years of age in Macao, from 2010 to 2021, has declined from 9.5% to 3.8% (in male from 8.2% to 3.6%, in female from 10.9% to 4%). These rates demonstrate the success of tobacco control policies in Macao (Table 3).

The countries and regions are ranked by the total MPOWER score, and the scores are obtained for each indicator for each activity. Macao ranks on the front position in Western Pacific for tobacco control and is on the second position after New Zealand (Table 5).

Discussion

This study showed that after a decade of legislation and implementation of the MPOWER measures between 2011 and 2021, the tobacco control policies and effectiveness in Macao compare favourably with other Western Pacific countries or regions. As compared to 2011, the tobacco control status in 2021 has improved by 16 points of MPOWER score. Individual indicators showed great improvement in the aspect of smokefree policies, health warning on cigarette packages, advertising bans and taxation.

Since the legislation on 1st January 2012, most of the indoor public places in Macao were prohibited from smoking, including the medical institutions, educational institutions, public institutions, indoor workplaces, restaurants, sports facilities, lifts, elevators, pedestrian bridges, and pedestrian tunnels, etc. The no smoking areas were then further extended to casinos, entertainment venues, parks, garden, bus station and taxi station. From 1st January 2019, except for the smoking lounges in airport and the designated smoking rooms in casinos, all indoor public places in Macao are completely prohibited from smoking.⁷

The law further strengthens the control over packaging and labelling of tobacco products. From 1st January 2013, packages of tobacco products must carry an authorised pictorial health warning, occupying at least 50% of the two principal display areas.⁷ This makes smokers aware of the health hazard of tobacco and strengthens their determination to stay away from tobacco. Virtually, all forms of advertising, promotion and sponsorship of tobacco and e-cigarettes are explicitly prohibited. Tobacco products are prohibited from being publicly displayed in general outlets such as supermarkets, convenience stores and newsstands. Tobacco products can only be displayed in the stores specialising in tobacco products.⁷ A series of restrictions aimed at reducing the exposure of tobacco products in society and their potential appeal to young people.

According to WHO, raising tobacco taxes to above 75% of retail price is the most effective and the most cost-effective tobacco control measures.⁴ In recent years, Macao has adjusted several times on tobacco taxes. There was an increase of 30 times in cigarette tax from 0.05 Pataca per stick in 2008 to 1.5 Pataca per stick in 2015. The current cigarette tax in Macau is about 60% of retail price, approaching the target of 75% as suggested by WHO, but there is still considerable room for improvement.⁷

Anti-tobacco mass media campaigns are an essential component of a comprehensive tobacco control programme. There is strong evidence that a welldesigned and hard-biting campaign can reduce tobacco use, increase quit attempts, and reduce exposure to second-hand smoke.^8,9 More efforts are still needed for Macao in this regard. Comprehensiveness and targeting are key elements of effective mass media campaigns. The messages of smoking cessation are most effective in environment aiming to make smoking less socially acceptable. The media should have a broad range which includes television, radio, print, outdoor billboards, online advertising, and transit advertising to reach more people. The messages should be continually and frequent enough to build awareness and change. Campaign tends to be more successful when targeting smokers more broadly rather than specifically.¹⁰ In the future, efforts should be spent more on media publicity with a broader range of coverage, especially via the mainstream media such as the internet and social media, and regular performance review should also be conducted.

The prevalence of tobacco and related products use in population >=15 years of age in Macao has declined by 34.3% in a decade since the legislation, from 16.9% in 2011 to 11.1% in 2022. Macao has reached the target for reducing tobacco use as suggested by the WHO Global Action Plan for the Prevention and Control of Non-communicable Diseases 2013-2020 for reducing the global prevalence of tobacco use (smoked and smokeless tobacco) by 30% by the year 2025 relative to 2010.¹¹ The prevalence of tobacco use in teenage population between 13-15 years of age has declined by 60% from 9.5% in 2010 to 3.8% in 2021. All these data demonstrated the success of tobacco control policies in Macao.

Limitation

This study does not analyse the improvement of MPOWER implementation and the decline of smoking prevalence on the impact of health or morbidity and mortality of smoking related diseases, such as cardiovascular disease or lung cancer.

Conclusion

Reviewing the ten years after the implementation of the MPOWER measures and legislation, Macao has great improvement on tobacco control policies and effectiveness, which compare favourably with other Western Pacific countries or regions. But there is room for improvement, especially in regard of tobacco taxes and mass media campaigns. Macao has reached the target for reducing tobacco use as suggested by the WHO and the prevalence of tobacco use in Macao remains low.

Acknowledgement

The authors gratefully thank the supervisor, related doctors and staff of Tobacco Prevention and Control Office of Macao for providing the necessary data and support in this research.

References