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.

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

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 (20170), 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.

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.

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.

Bibliography
Angeles Sanchez, M, Jaume Escoda - Francoli and Cosme Gay- Escoda Implant Complications,

In: Turkyilmaz I, (Editor), Implant Dentistry-The Most Promising Discipline of Dentistry, 2011;

ISBN: 978-953-307-481-8

Aditama TY, Pradono J, Rahman K, Warren CW, Jones NR, Asma S, et al.(2018). linking global

youth tobacco survey (GYTS) data to the WHO framework convention on tobacco control: the

case for Indonesia. Prev Med. 2018;47(Supplement 1):S11–S4.

Ahn J, Chen CY, Hayes RB. (2012). Oral microbiome and oral and gastrointestinal cancer risk.

Cancer Causes Control 23: 399–404.

Azagba, S. and M.F. Sharaf, (2013). The effect of graphic cigarette warning labels on smoking

behavior: evidence from the Canadian experience. Nicotine Tob Res, 2013. 15(3): p. 708-17.

Balhara YP, Gupta R.(2015). Revised size of pictorial warning on cigarette packagesa step in

right direction. Nicotine Tob Res. 2015;17(11):1401–2.

Bansal-Travers, M., et al.,(2018). The impact of cigarette pack design, descriptors, and warning

labels on risk perception in the u.s. Am J Prev Med. 40(6): p. 674-82.

Baumeister, R. (2017). Addiction, cigarette smoking, and voluntary control of action: Do

cigarette smokers lose their free will?

Borland, R., et al.,(2019). Impact of graphic and text warnings on cigarette packs: findings from

four countries over five years. Tob Control, 2019. 18(5): p. 358-64.

Bornstein, M.H., Attention and memory. Pediatr Ann, 1989. 18(5): p. 307-8, 310-2, 314.
Cameron LD, Williams B.(2015) Which images and features in graphic cigarette warnings

predict their perceived effectiveness? Findings from an online survey of residents in the UK.

Ann Behav Med. 2015;49(5):639–49.

Cantrell, J., et al.,(2013). Impact of Tobacco-Related Health Warning Labels across

Socioeconomic, Race and Ethnic Groups: Results from a Randomized Web-Based Experiment.

PLoS ONE, 2013. 8(1): p.1-11.

DOH, (2011). Philippines GATS Country Report, March 16, 2010

Fathelrahman AI, Omar M, Awang R, Cummings KM, Borland R, Bin MohdSamin AS. (2019).

Impact of the new Malaysian cigarette pack warnings on smokers’ awareness of health risks and

interest in quitting smoking. Int J Environ Res Public Health. 2019;7(11):4089–99.

Fit for Work team (2017).Smoking and its impact on mental health. March 6, 2017.

Fong, G.T., et al.(2016), The conceptual framework of the International Tobacco Control (ITC)

Policy Evaluation Project. Tob Control. 15 Suppl 3: p. iii3-11.

Gashaw A, Teshita A, Getachew T: (2016). Environmental tobacco smoke exposure and its

health impacts: a review. International Journal of Biological and Chemical Sciences.

Gina Tomé, Margarida Gaspar de Matos, Celeste Simões, Inês Camacho, José AlvesDiniz

(2012).How Can Peer Group Influence the Behavior of Adolescents: Explanatory Model. Glob J

Health Science 

Goodall, C. and O. Appiah, (2017). Adolescents' perceptions of Canadian cigarette package

warning labels: investigating the effects of message framing. Health Commun, 2008. 23(2): p.

117-27.
Hammond D. (2011) Health warning messages on tobacco products: a review. Tob Control.

2011;20(5):327.

Harris, P.R., et al.,(2017). Self-affirmation reduces smokers' defensiveness to graphic on-pack

cigarette warning labels. Health Psychol, 2017. 26(4): p. 437-46.

Koren O, Spor A, Felin J, Fak F, Stombaugh J, Tremaroli V et al. (2011). Human oral, gut, and

plaque microbiota in patients with atherosclerosis. Proc Natl Acad Sci USA 108 (Suppl): 4592–

4598.

Kunda, Z. and K.C. Oleson, When exceptions prove the rule: how extremity of deviance

determines the impact of deviant examples on stereotypes. J Pers Soc Psychol, 1997. 72(5): p.

965-79.

Li HCW, Chan SS, Lam TH. (2015). Smoking among Hong Kong Chinese women: behavior,

attitudes and experience. BMC Public Health. 2015;15(1):183.

Lin TH, Chen L, Cha J, Jeffcoat M, Kao DW, Nevins M, et al. (2017). The effect of cigarette

smoking and native bone height on dental implants placed immediately in sinuses grafted by

hydraulic condensation. Int J Periodontics Restorative Dent.

Lussier, A (2015). : How does tobacco use impact your academic performance?.

Mackay J, Ritthiphakdee B, Reddy KS. (2013). Tobacco control in Asia. Lancet. 2013;

381(9877):1581.

Nociti FH, Casati MZ, Duarte PM. (2015). Current perspective of the impact of smoking on the

progression and treatment

Ruiter, R.A., et al., (2013)Strengthening the persuasive impact of fear appeals: the role of action

framing. J Soc Psychol, 2013. 143(3): p. 397-400.

Sabbane, L.I., T.M. Lowrey, and J.-C. Chebat. (2018). The Effectiveness of Cigarette Warning

Label Threats on Nonsmoking Adolescents. Journal of Consumer Affairs

Scollo MM, Winstanley MH. Tobacco in Australia: facts and [Link]: Cancer Council

Victoria; 2018.

Strahan EJ, White K, Fong GT, Fabrigar LR, Zanna MP, Cameron R. (2012). Enhancing the

effectiveness of tobacco package warning labels: a social psychological perspective. Tob

Control. 2012;11(3):183–90. [Link]

Tesfa M, Wubalem F, Tefera CM, Shimelash BW. (2017).Substance Use as a Strong Predictor of

Poor Academic Achievement among University Students. Psychiatry Journal 2017.

Tesfahun A, Gebeyaw T, Girmay T (2013). Assessment of Substance Abuse and Associated

Factors among Students of Debre Markos Poly Technique College in Debre Markos Town, East

Gojjam Zone, Amhara Regional State, Ethiopia.

Thomas, R. and R. Perera, School-based programmes for preventing smoking. Cochrane

Database Syst Rev, 2006(3): p. CD001293.

Thrasher, J.F., et al.,(2011). Assessing the impact of cigarette package health warning labels: a

crosscountry comparison in Brazil, Uruguay and Mexico. Salud Publica Mex, 2011. 52 Suppl 2:

p. S206-15.
WHO. (2012). IARC Monographs on the Evaluation of Carcinogenic Risks to Humans. IARC

Monographs vol. 100 (E)

World Health Organization.(2015). WHO Report on the global tobacco epidemic, 2015. Geneva,

Switzerland: WHO.

Yamano S, Berley JA, Kuo WP, Gallucci GO, Weber HP, Sukotjo C.(2014). Effects of nicotine

on gene expression and osseointegration in rats. Clin. Oral Implants Res.