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June 3, 2021

Commit to quit

Abdul Sattar Edhi once said: “Even many poor who come to me for aid have a cigarette pack in their packet.”

On the occasion of this year's World No Tobacco Day (which fell on May 31), under the banner theme was the WHO message for smokers: "Commit to Quit". It says that the nicotine found in tobacco is highly addictive and creates dependence. In addition, the behavioural and emotional ties to tobacco use – like craving tobacco, feeling of sadness or stress – make it hard to kick the habit. With professional support and cessation services, tobacco users double their chances of quitting successfully.

Currently, over 70 percent of the 1.3 billion tobacco users worldwide lack access to the tools they need to quit successfully. This gap in access to cessation services is only further exacerbated in the last year as the health workforce mobilized to handle the pandemic.

In Pakistan, instead of smokers (surveys show that 70 percent want to quit), the commitment has to come from the government to provide so far nonexistent cessation service to the smokers. But how?

The government of Pakistan has been caught in the middle of a raging international debate among the healthcare and scientific community regarding use of vaping as a cessation aid The. WHO says wait. “The scientific evidence on e-cigarettes as cessation aids is inconclusive, and there is a lack of clarity as to whether these products have any role to play in smoking cessation. Switching from conventional tobacco products to e-cigarettes is not quitting."

However, based on multiple clinical trials – the gold standard in scientific research – many countries have started adopting vaping or HRPs (harm reduced products) along with WHO-approved NRT (nicotine replacement therapy) such as nicotine patches, nicotine gum and nicotine lozenges which are medically approved and widely used to help smokers quit by quelling their nicotine craving.

In contrast to NRT, currently marketed nicotine-containing e-cigarettes are not medicines – they are consumer products that offer a convenient, effective and safer way of replacing nicotine that would otherwise be obtained by smoking.

A clinical trial from a large New Zealand vaping population, funded by the Health Research Council in 2019, suggested that hundreds of thousands of more smokers worldwide could successfully quit the killer habit if they used nicotine-containing e-cigarettes (vapes) together with nicotine patches.

A major UK clinical trial published in 2019 found that people who used e-cigarettes to quit smoking were twice as likely to succeed as people who used other nicotine replacement products.

The Royal College of Physicians (RCP) recently released their UK report, ‘Smoking and health 2021: A coming age for tobacco control?’ This comes 60 years after they issued the world’s first authoritative report on smoking and health. The RCP estimates that if the harm-reduction policies they advocated for in 1962 were adopted, smoking would have ended in the United Kingdom by now. Their new report calls for doctors to play a more active role in helping their patients who smoke. The RCP says, “We argue that responsibility for treating smokers lies with the clinician who sees them, and that our NHS should be delivering default, opt-out, systematic interventions for all smokers at the point of service contact.”

The RCP also recommends that the UK government invest in media campaigns to urge smokers to switch from tobacco to e-cigarettes, which are less harmful. Governments and doctors worldwide should heed their advice.

“While nicotine is the addictive substance in cigarettes,” the United Kingdom's National Health Service NHS website says, “it's relatively harmless. Almost all of the harm from smoking comes from the thousands of other chemicals in tobacco smoke.”

In Sweden, snus, moist powdered tobacco, has become a popular cessation aid. While many countries, mainly developed, have adopted vaping as a cessation aid within the ambit of the FCTC, many developing countries have banned e-cigarettes.

Pakistan’s Ministry of National Health Services, Regulations and Coordination (NHSRC) ratified the FCTC (Framework Convention on Tobacco Control) 16 years ago but only added NRT as part of the essential drug list in 2018. Still, these cessation aid medicines are not available in government hospitals but in expensive private sectors that remain inaccessible to the poor.

Even though imported vaping products, after paying 20 percent customs duty, have penetrated the high and middle-income urban centres but when asked by the WHO, in a classic ostrich approach, the NHSRC reported it has no data on these innovative products.

The WHO differentiates between NRT and HRPs, calling the latter novel and emerging tobacco and nicotine products including Heated Tobacco Products (HTPs), Electronic Nicotine Delivery Systems (ENDS), Electronic Non-Nicotine Delivery Systems (ENNDS) and other products.

In 2000, the WHO asked the parties to the FCTC to also report on the use of novel and emerging tobacco and nicotine products saying that monitoring ENDS among adults and adolescents is essential to understand the level of use and the trends. Countries began collecting data on the current use of ENDS in 2013, and 42 countries now have nationally representative data available. However, the WHO says, the indicator is not yet collected in enough countries to estimate the global level of use.

The tobacco in HTPs may be in specially designed cigarettes (heat sticks or Neo sticks) or pods or plugs. HTPs differ from conventional cigarettes and ENDS – some of which are called e-cigarettes – as ENDS do not contain tobacco but rather a nicotine solution.

However, the WHO notes that the boundaries between the different products are becoming increasingly difficult to define, given the emergence of so-called hybrid tobacco products containing both nicotine solution and tobacco.

Pakistan needs to provide cessation to around 15 million of its adult population which smoke. The report, ‘The Economic Cost of Tobacco Induced Diseases in Pakistan-2021’, released by PIDE, records that the total costs attributable to all smoking-related diseases and deaths in Pakistan for 2019 are Rs615.07 billion ($3.85 billion). The indirect costs (morbidity and mortality) make up 70 percent of the total cost.

“Smoking-attributable total direct and indirect cost of cancer, cardiovascular and respiratory diseases amount to a total of Rs437.76 billion ($2.74 billion) which is 3.65 times higher than the overall tax revenue from the tobacco industry (120 billion in 2019),” PIDE estimates.

And poor households are more affected. A study of the Social Policy and Development Centre, Karachi says that basic food is the commodity that is most affected by tobacco use in lower-income households. Moreover, low-income families devoted more of their budget to tobacco as compared to wealthy households.

Pakistan can save this economic cost by exercising its sovereign right to decide that, since the country does not have resources to extend cost effective NRT to people who smoke, it may want to look into adopting readily available HRPs as cessation aid.

The writer is a freelance contributor.

Email: [email protected]