Far from the promise of endgame, tobacco epidemic continues...

Shobha Shukla *

Tobacco industry-propelled epidemic of tobacco-caused diseases and untimely deaths continue to plague human development. Despite significant progress on tobacco control, endgame of tobacco - which is a human rights and social justice imperative - is not yet in sight. The recently released 7th edition of Tobacco Atlas shows that while global smoking prevalence in adults has declined from 22.7% in 2007 to 19.6% in 2019, we still have 1.3 billion tobacco users in the world.

The progress on the endgame of tobacco is threatened by the growing tobacco smoking rates among children aged 13 to 15 years in many countries, and by tobacco industry tactics targeting poorer countries with weak regulatory environments and pushing so-called 'novel' products in previously untapped markets.

It is a warning call to all those who care about global health and economic development. Urgent and sustained efforts are needed to aggressively regulate the harmful tobacco industry and its products to save lives, and spur economic growth, said Jeffrey Drope, lead author of the Tobacco Atlas.

Tobacco use remains a global epidemic. Besides being a major risk factor for non-communicable diseases, it leads to an estimated nearly 9 million deaths globally every year (almost 8 million deaths due to tobacco use and 1 million deaths from exposure to second-hand smoke) and economic losses of nearly USD 2 trillion. 1.9 million (21%) of these deaths occur in the World Health Organization (WHO)'s southeast Asia region that comprises 11 countries- Bangladesh, Bhutan, DPR Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste.

With 26% of the world’s population, the southeast Asia region reported the highest prevalence of tobacco use (28%) amongst all WHO regions globally in 2020. The region is not only one of the largest producers and consumers of tobacco products globally, but is also home to 20% of world’s adult smokers (241 million) and 34% (14.8 million) of the world’s tobacco consuming young population (13-15 years). Moreover, it has 82% (301 million) of the global smokeless tobacco (SLT) users and boasts of having the highest prevalence (7.3%) of SLT use in young people.

And this is despite the fact that all countries of the region, except Indonesia, having ratified the WHO Framework Convention on Tobacco Control (WHO FCTC) that aims to protect everyone from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke. It provides the foundation for countries to implement and manage tobacco control through MPOWER-a set of six cost-effective key strategies to fight the global tobacco epidemic. But compliance of these strategies remains poor.

Although current tobacco use among adults in Indonesia is high at 34%, it is still less than that in Myanmar (54%), Timor Leste (49%), and Bangladesh (35%). In fact, current tobacco use among adults in the region is highest in Myanmar.

Bhutan has won accolades for being the only country in this region (and in the world) that has banned the production, manufacturing and sale of all tobacco products since 2004 - the same year it had ratified the global tobacco treaty (WHO Framework Convention on Tobacco Control). Yet, as per the Tobacco Atlas (2020) for WHO southeast Asian region, current tobacco use in Bhutan is 25%, which is higher than that in DPR Korea (22%), Thailand (21%) and Maldives (20%).

It also has the second highest percentage of young tobacco users (22%) in the region after Timor Leste (42%). Prevalence of tobacco smoking is also high at 17% , which is just second to Indonesia (19%).

Similarly in smokeless tobacco use, Bhutan at 13% is second to Nepal (16%). One reason for this high tobacco consumption could be that its 2010 directive allowed a heavily taxed and controlled import of tobacco products. Moreover, in 2020 it lifted this ban, purportedly to reduce the risk of imported Covid-19 infections arising out of cross border smuggling of tobacco products.

Nepal is the only country in southeast Asia region which has banned the use of all kinds of tobacco products in public places, including smokeless tobacco products, since 2011. But, it has the highest prevalence of smoking among women (10%) in the region.

When it comes to the youth (13-15 years), Timor-Leste boasts of highest smokeless tobacco use at 42% as well as highest prevalence of tobacco smoking at 35%.

Tobacco industry interference is alarmingly high

Tobacco industry interference is high, with 3 big transnational tobacco companies- Philip Morris International (PMI), British American Tobacco (BAT) and Japan Tobacco International (JTI) - dominating the southeast Asia region. Bangladesh, Indonesia and India have high tobacco industry interference in policy development. Their tobacco industry interference index (on a scale of 100) are 83, 79 and 72, respectively.

Tobacco industry's dominance and interference under the garb of their corporate social responsibility (CSR) activities, and governments' involvement with the industry through owning their shares and nominating key government officials to hold positions in tobacco companies through the revolving door policy, hinder proper implementation of tobacco control measures, had said Barrister Shameem Haider Patwary, the firebrand Member of Parliament (MP) from Bangladesh, who was speaking as faculty in Johns Hopkins School of Public Health's South Asia Leadership Course on Tobacco Control. He called for a very strong political leadership, high political commitment, adequate resource allocation and a holistic approach at national, regional and global levels for effective tobacco control initiatives in this region.

Dr Tara Singh Bam, Asia Pacific Regional Director of The International Union Against Tuberculosis and Lung Disease (The Union) said to CNS (Citizen News Service): “Tobacco industry tactics to thwart, dilute and delay implementation of tobacco control measures can be countered by building a team that goes beyond the health sector and involves academia, media, teachers, politicians, lawyers, social volunteers. It has to be team work. We have to be persistent in our efforts through sustained engagement with governments to make them accountable so that they in turn make the industry accountable. We have to build local leadership to support tobacco control efforts at national and regional level.”

Good practices are there but scale up too slow

However there are some good practice examples too. There is a ban on tobacco advertising in all countries of the region and all countries, except Indonesia, have banned smoking in public places. Nepal, Maldives and Thailand have banned advertising, promotion and CSR activities of tobacco companies. E-cigarettes are banned in 6 out of 11 countries of southeast Asia region- Bhutan, India, Nepal, Sri Lanka, Thailand and Timor-Leste. Thailand imposes a very high tax of 78.6% on cigarettes.

Some countries have also made good progress in implementing larger pictorial/graphic health warnings (PHW) on tobacco products, which is an evidence backed effective measure to reduce tobacco use. Timor Leste has enforced the largest PWH (92.5%) on tobacco packs, followed closely by Nepal (90%), Maldives (90%), India (85%) and Thailand (85%).

Nandita Murukutla, Vice President of Research at Vital Strategies, calls for increasing tobacco taxes as they can drive down smoking rates, deter initiation among youth, and generate revenue that can pay for other health interventions. She cites graphic pack warnings and plain packaging as other proven high-impact, low-cost interventions, and insists upon investing more in media as media campaigns can reshape social norms and drive millions to quit.

Tobacco not only damages the health of people but also destroys our environment, through the cultivation, production, distribution, consumption, and post-consumer waste of tobacco products. Keeping this in mind, the theme of World No Tobacco Day 2022 is “Tobacco: Threat to our environment”.

It aims to raise awareness among the public on the environmental impact of tobacco and to expose efforts by tobacco companies to “greenwash” their reputation by marketing themselves as environmentally friendly. This global campaign calls for reducing tobacco consumption as a key lever for achieving all of the Sustainable Development Goals and not just those directly related to health.