Thursday June 30, 2022

Tobacco use: the bigger picture

May 30, 2020

Are we going towards a scenario where cigarettes are replaced with safer nicotine delivery products like vaping or e-cigarettes under well-defined safety standards, and strict laboratory scrutiny whereas the nicotine products remain inaccessible to the youth?

This will be a ‘win-win’ for all – the 300 billion rupee tobacco economy grows, health costs are massively reduced, the livelihood of farmers are secured, and the government is generating more revenue.

This can be done while exerting the country's sovereignty but remaining within the boundaries set by the WHO’s Framework Convention on Tobacco Control (FCTC).

However, given the track record, different federal ministries and provincial governments are not going to do anything like that and will continue with the policy of taking piecemeal measures that have the minimum possible impact to reduce tobacco prevalence.

The challenges are two-fold – to secure youth from all kinds of tobacco or nicotine products as is enunciated by World No Tobacco Day, which falls on May 31, and provide cessation facilities to around 14.7 million Pakistanis above 15 years of age that they can quit smoking.

While holding the portfolio of health, Prime Minister Imran Khan is in an ideal position to evolve a comprehensive strategy involving all the stakeholders. These include the political entities allegedly involved in the illicit tobacco business and which allegedly are the backbone of the governments in Khyber Pakhtunkhwa and the centre, the healthcare community, farmers, industry and revenue collectors.

The WHO global report on trends in the prevalence of tobacco use 2000-2025 says tobacco use reductions among men are proving particularly difficult for achieving the target of the SDG to reduce prevalence by 30 percent by 2025. Yet, there are indications that the tide is finally turning.

In Pakistan in 2018, using 2014 data, the projected number of tobacco users and tobacco smokers aged 15 years and older are estimated as 21 million. Of them, men are 19.5 million, while women are 1.5 million.

WHO data does not include statistics about electronic nicotine delivery systems (ENDS), of which electronic cigarettes are a common type. Electronic cigarettes are devices that heat a liquid to create an aerosol inhaled by the user. The liquid contains nicotine (but not tobacco) and other chemicals that may be toxic to people's health. The WHO says that monitoring the use of ENDS among both adults and adolescents is essential for understanding the level of use and the trends.

The WHO also says that 70 percent of smokers want to quit smoking, which can be applied to Pakistan. By this estimate, the government needs to provide cessation facilities to 14.7 million people. This is only next to impossible.

In the proposals for the upcoming budget, the Ministry of National Health Services Regulations and Coordination (NHSRC) wants to have more budgetary allocations, not for cessation facilities but for treating the people of diseases caused by tobacco. However, given the fact that already the federal government is charging federal cess on tobacco and excise duty whose rationale is to charge a smoker for causing health damage to himself and third person, the proposal may fall on deaf ears of budget designers of the finance ministry.

The new pathways for “quit smoking” can be found in the UK public-funded National Health Service (NHS) approach, which has started using ENDs as a policy to help people quit smoking. The NHS says that many people find e-cigarettes – also known as vapes – helpful for stopping smoking. E-cigarettes aren't entirely risk-free, but they carry a small fraction of the risk of cigarettes. Quitting with an e-cigarette is particularly effective when combined with expert face-to-face support, says the NHS.

This has been corroborated by leading British health organizations, including the Royal College of General Practitioners, British Medical Association, and Cancer Research UK. They say that e-cigarettes are far less harmful than smoking.

Japan also followed the same strategy where ENDs (non-combustion products) or heated tobacco products (HTPs) use is outpacing cigarettes. Japan has been a testing ground for HTPs. IQOS (“I Quit Ordinary Smoking”), marketed by Philip Morris International (PMI), was first introduced in 2014, followed in 2016 by the launch of Ploom TECH by Japan Tobacco International (JTI) and glo by British American Tobacco (BAT). According to market analyst reports, Japan has the most developed HTP market of all countries worldwide, accounting for 85 percent of HTP sales in 2018.

Since 2016, the American FDA (Food and Drug Administration) has included ENDS that meets the definition of a tobacco product. FDA regulates the manufacture, import, packaging, labeling, advertising, promotion, sale, and distribution of ENDS, including components and parts of ENDS. Many countries adopt these non-coercive strategies in the face of ineffective use of the traditional nicotine replacement therapies (NRTs), such as patches or lozenges, which could not offer much help for smokers to quit.

Pakistan's state policy is in a state of limbo. Much to the dismay of the KP government, the Pakistan Tobacco Board (PTB) that regulates the tobacco crop and which was previously under the Federal Ministry of Commerce has been placed under the control of the Ministry of National Food Security & Research (MNFSR). The MNFSR is responsible for policy formulation, economic coordination, and planning in respect of food grain and agriculture. It also includes the procurement of food grains, fertilizer, import price stabilization of agriculture produce, international liaison, economic studies for framing agricultural policies. Now tobacco is also part of the Pakistan National Food Security Policy.

The tobacco economy makes an exciting read. At present, the tobacco crop is standing in the fields of three provinces. Harvesting will start in around June and July; 45 million kg of this tobacco crop, which is enough to produce 45 billion sticks, is already bought by the manufacturers under the price fixed by the PTB. Of 45 million, two multinational companies have secured 33 million kg. The remainder has gone to 48 different local companies.

But this is less than half of the total production of tobacco, which is around 106 million kg, an average national total output.

The PTB has fixed the price of different varieties between 2.21 to 4.46 rupees per kg. If we calculate by an average of 126, then these companies will be paying 6.5 billion rupees to the around 2,000 farmers. The PTB will be earning approximately Rs150 billion on account of federal cess.

During the ongoing financial year, the FBR’s revenue has declined because of the declining sale of duty paying cigarettes from 65 billion sticks in 2018-19 to 43 billion sticks in 2019-20. The 22 billion sticks have gone to the illicit tax non paid cigarette category that is managed by KP’s politically influential businessmen. The tax revenues also slashed from Rs124 billion in FY 2018-19 to Rs116 billion in the current fiscal year. Against the desired target of Rs147 billion, the FBR has been facing a shortfall of Rs31 billion in the outgoing fiscal year.

Given the fact that since the constitutional devolution of health to provinces a decade ago, the NHSRC has been struggling to create a niche for itself in the health system policymaking. However, its role in drug regulation through the Drug Regulatory Authority of Pakistan (DRAP) is well established. If the NHSRC decides to add ENDs with NRTs, it can set its safety standards and regulate the manufacture, import, packaging, labeling, advertising, promotion, sale, and distribution. Otherwise, market forces have already taken their course, and ENDs are very much available unregulated everywhere.

The writer is a freelance contributor.