What can we do to control the tobacco epidemic in Pakistan?

Tobacco use in any form is deadly. Smoking kills more then half of all regular users, and the smokers die on average of 15 years earlier than non-smokers. Tobacco related mortality is increasing rapidly in Pakistan. According to a WHO 2008 report 32% males and 6% females smoke in Pakistan. Youth smoking prevalence is from 10% to 15%.

A significant number of people also use smokeless tobacco in the form of Paan, Gutka, Naswar etc. Pakistan Tobacco Company reported 17% rise in its sales from January to September 2008 compared to 2007. Rise in profit of 9.3% was from the increased sales volume and rest because of increase in the price of cigarettes. In order to curb the growing tobacco epidemic in Pakistan we do not need to re-invent the wheel. Several tobacco control measures have proven track record, which if implemented in Pakistan can slow down the tobacco epidemic. Some of these measures are described below.

A. Smoke Free Public and Work places

Tobacco smoke pollution (TSP) causes number of diseases including Lung cancer, heart attacks, pneumonia and exacerbation of asthma. Comprehensive smoke free policies and its implementation improve health, motivates smokers to quit and help reduce tobacco consumption.

Unfortunately our law which calls for prohibition of smoking at all public places is not being implemented in the country. Research has shown that smoke free policy is only effective if all indoor public places are completely smoke free. Its effectiveness is weakened if designated smoking areas are allowed.

Suggested Measures;

Following measures are suggested to implement the law

• Mass Media campaign on the need for smoke free indoor public places..
• Strong message from MOH to all hotel chains, restaurant owners, banks, hospitals, educational institutions asking them to implement the law.
• Random checks from Tobacco Control Committees at provincial and city government levels.
• Impose fine if law is violated by any organization.
• Law must be respected and implemented at all government offices as well in Assemblies and Senate..
• Ban on smoking should include “Shisha” use at all hotels and restaurants.

B. Effective Health Warnings on Tobacco (Cigarette Packs)

Smokers tend to underestimate the health risk of tobacco use. Effective health warning on cigarette packs encourages smokers to quit and discourage non-smokers particularly the youth from starting. Health warning need to use strong, clear language and must include “pictures” highlighting the health risk associated with tobacco use.

Suggested Measures;

• Pictorial health warning should be introduced on all tobacco products. Warning should be large, covering at least 50% of display area on all main faces of the pack. Pictures must display the serious health hazards associated with tobacco use and the picture warning must be rotating.
• Ban the use of misleading term like light or mild on cigarette packs.

C. Comprehensive Ban on Tobacco Advertising and Promotion

At present the ban on tobacco advertising is only partial in Pakistan. Such partial ban does not work. Comprehensive ban on tobacco advertising has shown to decrease tobacco consumption in many countries. After partial ban on TV, now more smoking scenes are shown on TV drama serial. Point of sale advertising has markedly increased in Pakistan.

Tobacco industry continues to promote tobacco through youth magazines, mobile cinema halls and free distribution of cigarettes at musical concerts. All so called lucky draws and prize scheme which are announced by the tobacco industry from time to time must be stopped.

Recommendations

• Existing laws must be amended to make way for a comprehensive ban on all direct and indirect forms of tobacco advertising, promotion and sponsorship. It should include advertising at shops where tobacco is sold.
• Impose substantial penalties on those who breach the ban.
• All TV channels must be directed to stop showing scenes of smoking on talk shows or drams serials.
• The so called corporate social responsibility is being used to advertise and promote tobacco companies and indirectly their products. It must be stopped.
• Indirect advertising of tobacco companies in the form of mobile dispensaries, medical camps, and blood donation camps must not be allowed.
• Shops selling tobacco to less than 18 ages must be fined on the spot.

D. Tobacco Taxation

Recent survey shows that cigarette price in Pakistan are the cheapest in the region. Increasing the price of tobacco via taxation is the single most effective way of reducing tobacco consumption. Cigarette consumption falls when taxes rise. Price increase encourages people to stop smoking, prevent others from starting smoking and discourages ex-smoker from starting smoking again. A price rise of 10% decreases tobacco consumption by about 8%.

Recommendations

• Tobacco taxes should be increased and ideally it should be between two third and four fifth of the retail price.
• Special “Health Tax” on cigarette pack should be introduced. Money generated should be used for mass media campaign against the tobacco.

E. Smoking Cessation

Majority of smokers realize the need to give up smoking but find it difficult to do so in the absence of any organized efforts to do so. Also there is no formal training of health care providers on smoking cessation. Telephones quit lines are in its infancy in Pakistan. All 3 smoking cessations medications are now approved by the MOH which can help motivated people in giving up this powerful addiction.

Recommendation

• Medical school curriculum should include tobacco control and smoking cessation.
• Special workshops must be arranged for GP’s and well as for the hospital doctors on building their smoking cessations skills.
• Health care providers in BHUs and THQs should be provided with simple tools enabling them to assist patients with smoking cessation.
• Pharmaceutical companies should be asked to provide quit smoking medicines at affordable price.

F. Public Health, Mass Media Campaign

Despite conclusive evidence of the dangers of tobacco, relatively few tobacco users fully grasp its health risk. Most people generally believe that it is simply a bad habit. The extreme addictions of tobacco and the full range of health dangers have not been adequately explained to the public.

Suggestive Measures;

• Anti Tobacco advertisements must be shown on electronic and print media.
• Educate the public on the dangers of tobacco use on various health days e.g. No Tobacco Day, Stroke Day, Diabetes Day, Heart Day, Kidney Day, Hypertension Day and TB day. On these days all electronic media are looking for “news” related to these public health issues.
• World Lung Foundation has prepared a series of videos, which can be aired by our TV channels at no extra cost.
• Anti tobacco laws must be publicized through electronic and print media.
• School curriculum should include tobacco as a subject and the Ministry of Education must be involved in this process.
• Religious scholars must be involved to propagate anti tobacco message at religious gatherings.
• All professional medical/nursing organizations must be engaged in anti tobacco campaign.

G. Tobacco Cultivation and Crop Substitution

Pakistan is a tobacco growing country. Tobacco farming is very profitable for the multinational companies, small farmer fall into a debt trap perpetuated by tobacco companies. WHO Framework Convention on Tobacco Control (FCTC) calls governments for financial and technical assistance to tobacco growers. Shifting to nutritious, economies viable and environmentally sound alternative crop would promise a bright future for Pakistan. Tobacco is not good for any countries economy; in fact it makes poor country even poorer.

Suggestive Measures

• Pakistan tobacco board instead of working for promoting tobacco growth and its export should work for crop substitution.
• Income support should be provided to tobacco farmer until the process of diversification is complete and sustainable.

H. Tackling Illicit Trade

There are three verities of illicit trade in tobacco, smuggling, tax evasion and counterfeiting. All three practices contribute to increasing the availability and accessibility of cigarette in the market and more losses to the exchequer.

Suggestive Measures

• Enhance law enforcement and international cooperation and prosecute illicit trade.
• Cigarette companies should control their distribution chain, with serious penalties and tax liabilities for failure to do so.

I. Monitoring Tobacco Use and Prevention Policies

We need data in Pakistan on the current prevalence of tobacco use in adults, youth; females’ etc. We also need to measure the health care cost of managing tobacco related diseases. Policy makers much have access to this data. Smokeless tobacco use is also a growing problem in the country but little epidemiological data exists to plan future strategies. However for doing any research no funding should be accepted from the tobacco industry.

Suggestive Measures

• Research should be carried out to see the prevalence of various tobacco uses in different sections of the society.
• Surveillance mechanism must be in place for monitoring tobacco use trend.

J. Tobacco Litigation

There are several successful example of tobacco litigation in the developed world. Tobacco litigations were started in USA but this is clearly increasing around the world. WHO encourages litigations for purpose of tobacco control.

Suggested Measures

• Patients, who suffered from tobacco related illnesses can claim heath care cost recovery from tobacco companies.
• Some selected lawyers should be provided training on tobacco litigation.
• Legal actions can be taken against fast food chain and other multinational organizations which are not implementing Pakistan’s clean air laws.
• Tobacco companies can be taken to courts for false clams like light/mild cigarettes.

REFERENCES

1. Beaglehole R, Ebrahim S, Reddy S, Voute J. Preventation of chronic diseases: a call to action. The Lancet 2007, 370, 2152-2157.

2. A Begonde DO, Mathess CD, Adam T, Ortegon M, Strong K. The burden and cost of chronic disease in low-income and middle-income countries. Lancet 2007: 370, 1929-1938

3. Nishtar Sania et all Tobacco control: National Action plan for NCD prevention, control and Health promotion in Pakistan. JPMA December 200 (S 3) N 12 S31- S84.

4. The Tobacco Atlas third edition, American Cancer Society, World Lung Foundation 2009.

5. Wasay Mohammad, Jabbar Abdul. Fight against chronic disease in Pakistan. Cost effective interventions. JPMA April 2009. Editorial Vo 59 No  196-197

6. WHO report on Global Tobacco Epidemic 2008. The MPower package WHO: 2008

Javaid A Khan is FRCP (Edin), Chair National Alliance for Tobacco Control, Professor of Medicine, Section Head of Pulmonary and Critical Care Medicine and Consultant Chest Physician at the Department of Medicine at The Aga Khan University.