Tobacco

Mr Zia Banday

1. Context

On 18^th May 2004, Pakistan signed Framework Convention for Tobacco Control (FCTC), which was ratified by the government on 3^rd November 2004. FCTC is first of its kind multilateral treaty initiated by World Health Organization (WHO), after years of evidence-backed advocacy. It is meant for comprehensive tobacco control regime on global level. This rapidly embraced treaty is ratified by 181-countries, which comprises of over 90% of the world population. FCTC provides a structured approach for tobacco control under its MPOWER paradigm, which consists of following 6-components:

• M – Monitor tobacco use and prevention policies
• P – Protect people from tobacco smoke
• O – Offer help to quit tobacco use
• W – Warn about the dangers of tobacco
• E – Enforce bans on tobacco advertising, promotion and sponsorship
• R – Raise taxes on tobacco

As a pivot, WHO is not only providing technical assistance and network linkages to FCTC member countries for capacity building and project initiation, but also publishing regular performance reports to benchmark countries progress on tobacco control. As supplementary to FCTC, WHO also initiated a Protocol to Eliminate Illicit Trade in Tobacco Products in 2013. Pakistan is included among 54-countries, who have ratified the protocol, which came into effect on 25^th September 2018. It is pertinent to mention here that governmental efforts around the world on tobacco control didn’t commenced with FCTC. Tide of public opinion against tobacco usage especially cigarettes has started emerging with the presentation of scientific evidence of linking cigarette smoking with cancer in sixties. However, this journey for restricting tobacco usage remains much arduous in subsequent decades owing to large pull of Big Tobacco companies. Situation did change for better for tobacco control initiatives, but the struggle is going on.

Much has happened on tobacco control front in Pakistan since the government’s ratification of FCTC in 2004. It has made considerable progress on compliance with benchmarking, as envisaged under different components of MPOWER paradigm. For the first time, Pakistan has conducted a country-wide Global Tobacco Adult Survey in 2014, which provides much useful information on tobacco usage for the design of subsequent interventions. However, effective implementation on ground and related gaps will makeup of an interesting read later in this paper.      

For the effective design of Tobacco Control measures, a holistic comprehension of the prevalent nicotine ecosystem is essential. Over the years, this ecosystem is evolving with diversified stakeholders striving to push their agenda through innovation in both regulatory and product paradigms. With FCTC, much convergence has been witnessed on the governance approach for reducing tobacco usage across jurisdictions in the last 19-years. However, big tobacco companies and participants in tobacco value chain are showing agility in covering their revenues in this increasingly strict regulatory environment.

In 2020, global retail sales of cigarettes, predominant medium for tobacco sales, touched the figure of 5.2 trillion sticks. And if we include the sales of illicit cigarettes, then this figure rises to 5.6 trillion sticks. In comparison to 2017 legit cigarette sale figures of 5.4 billion sticks, it seems that smoking is on the decline. However, as it is said that devil lies in the details. Total market size of the nicotine ecosystem is estimated at USD 852.9 billion for 2020, out of which cigarettes alone holds a share of 84.1% with an annual sales of USD 717.3 billion. In value terms, it has registered a steady CAGR of 2.7% despite fall in volume, but this value enhancement will be attributed to imposition of higher taxes in different jurisdictions. However, other products such as vaping, heated tobacco, smokeless tobacco and oral nicotine are increasing their share in the pie of nicotine ecosystem. It is pertinent to mention here that a significant segment of culturally specific tobacco products such as Gutka, Pan Tobacco and others are not covered in these figures. 

Situation on the tobacco control front is bit tricky in Pakistan. Government has undertaken various regulatory interventions to curb the public usage of tobacco. On paper, consumption of legit cigarettes is on the decline, but if the volume of illicit cigarettes is included then smoking is sustaining a stable growth. In comparison to global average of 8% share of illicit cigarettes in total market, the same ratio stands at 37% in Pakistan. Lax regulatory enforcement coupled with enhanced taxation on cigarettes is furthering grey market for both consumers and producers. As per global adult tobacco survey of 2014, the cigarette smoking prevalence rate is at 10.4% in Pakistan. If the adult smoker population is extrapolated at a declining rate, then it will be 14.3 million in 2021. Against the total market size of 98,206 million sticks, average annual consumption per smoker will be 6,848 cigarettes or 19 cigarettes daily. It may be interpreted as that cigarette smoking prevalence rate is under reported, in actual the number is much larger in Pakistan.

Another big challenge in effective tobacco control in Pakistan is the existence of large segment of non-cigarette tobacco consumers, whose prevalence is 7.7% or 11.3 million in population. Overall this segment is much less regulated with little research available on its dynamics. 

Globally a more hybrid structure is emerging in place of conventional tobacco control measures. With persistent advocacy against tobacco usage over decades, a commercially viable space is created for products pertaining to Nicotine Replacement Therapy (NRT). Number of pharma and even tobacco companies are entering in this NRT segment to nurture revenues. In the universe of tobacco control, measures are broadly segregated among prevention, protection and cessation categories. Against the big money and ingenuity pull of tobacco companies and entities, it remains an uphill task of reducing the footprint of tobacco in the country. Even with stringent curbs on advertising and ever increasing taxation load, top tobacco companies are still making large profits and contributing to national exchequer. Even without marketing gimmicks, demand for tobacco products and especially cigarettes is sustained over its legacy and life style attractions. And its impact is most lethal on the young population of age bracket of 15-29 years, which is the largest adult segment in Pakistan with a share of 27% in total population or 61 million in number. 

With this perspective, this write-up will strive to explore a sustainable path for devising an effective design of tobacco control measure that incorporates the Pakistan-specific peculiarities. A lot of groundwork has been done by the government and other stakeholders in the area of tobacco control since ratification of FCTC by Pakistan in 2004. We will review these interventions and identify gaps for improvements. The write-up is divided into four sections. In the first part, a review of the evolving global tobacco control paradigm will be presented along with lessons learnt. The second section will cover the prevalent tobacco ecosystem in Pakistan and its dynamics. Third section will highlight the government initiatives for tobacco control and its ensuing gaps. Last section will elaborate on evidence backed and actionable tobacco control strategies for Pakistan.

2. Global Overview of Tobacco Control Paradigm

Globally, 1.3 billion tobacco users make up 22% of the world population of 15-years and above. Owing to robust and persistent anti-tobacco efforts, this tobacco prevalence rate has come down from the high of 34.2% in 2000. However, much of this reduction could be attributed to figures emanating from developed countries, which have been implementing harsher tobacco control regulations for long. China National Tobacco Corporation is the largest cigarette producer with 48% global market share, but it is majorly restricted to one-country only, i.e. China. It is followed by four large multinational tobacco companies, namely Philip Morris, British American Tobacco, Japan Tobacco and Imperial Brands, collectively known as ‘Big Tobacco’. These large enterprises have annual earnings to the tune of tens of billion dollars and have presence in across every region of the world. 

It is evident that stringent tobacco control will be anathema for the profitability of Big Tobacco. From self-interest perspective, their interference in diluting the impact of regulatory measures for reduction in tobacco usage, is a well-established fact. In USA alone, tobacco industry has spent $30 million on federal level lobbying only in 2022. Its tactics include influencing law makers for favorable legislation, front research organizations for denying evidence against tobacco usage, image building through corporate social responsibility activities, media articles and sponsoring events. Its influence is much more prevalent in developing countries with lax implementation on tobacco control regulations. With the building up of the regulatory pressure, tobacco industry is using the tech ingenuity for introducing innovative products such as e-cigarettes and heated tobacco under the guise of Harm Reduction Products (HRM). Big tobacco is even acquiring pharmaceutical companies, engaged in the production of nicotine products, to make up for the lost cigarette sales. 

Against this well-entrenched oiled machinery, a network of multilaterals, non-government organizations and civil society is striving to save imminent fatalities caused through tobacco consumption. Over 80% of the current tobacco users are based in low-middle and low income countries. Tobacco induced diseases are causing 8 million deaths on yearly-basis. Under FCTC, member countries are operating at different compliance levels for MPOWER components, as tabulated below:

As per WHO report, out of 181-FCTC member countries, 98 countries have been able to achieve high compliance with at least 2-MPOWER components. Countries with better compliance performance are highlighted below:

• 31 Countries with high compliance in 3-measures
• 5 Countries with high compliance in 4-measures (Jordan, Ireland, Madagascar, New Zealand & Spain)
• 2 Countries with high compliance in all measures (Brazil & Turkey)

Demographics of FCTC member countries on high compliance with different MPOWER components are elaborated below:

It is evident that FCTC does provide a structural approach for countries to follow and enhance their tobacco control capacity, but around half of its members have remained away from implementing any MPOWER measure. Even in participating members, tobacco cessation area remains much neglected, which impacts sustained quitting by existing smokers in a negative manner. Number of member countries are successfully utilizing high taxation policies to reduce demand for tobacco products, but it is also inducing huge black market of smuggled and untaxed cigarettes in large countries, such as Brazil, India and Pakistan. It is creating a dual challenge for the government to overcome illicit trade of tobacco products at one end and they also have to suppress demand from low-income segments for such products.

Another governance area is emerging at the high flow end of Electronic Nicotine Delivery System (ENDS) and Heated Tobacco Products (HTPs). Hiding behind the façade of harm reduction, tobacco industry is flooding the global markets with a vast array of EDNS and HTP products. In a decade, these two categories have reached a yearly global sale value of around USD 42 billion and are registering a double digit annual growth rate. Combustible cigarettes still contribute the lion share in the revenues of tobacco industry, but its volumetric growth is on the decline, which is made-up by these innovative offerings, which are available in an array of sleek design and cater for numerous taste buds with varied flavors. Tobacco industry is lobbying with different governments to treat EDNS and HTPs as less risky and even as tobacco cessation product. It is creating challenge for regulators in various jurisdictions, where tobacco industry has been successful in allowing sales of EDNS and HTPs. 

Tobacco has been a cash crop for the farming community around the world. Tobacco growers have stable relationship with the tobacco industry spanning over decades with a legacy. It is evident that this relationship is not going up in thin air with all the imposition of regulatory restrictions on curbing tobacco supplies. Over the years, area under tobacco cultivation has reduced worldwide, but with higher productivity, agro economy of tobacco has been able to sustain its production. From the peak of 7.6 million tons in 2013, tobacco production has come down to 5.9 million tons in 2021. With ample productivity available, tobacco growers can ramp up the production along with market demand. Tobacco farmers doesn’t seem to be much enthusiastic to wholesale switching to alternative crops. It requires strenuous efforts and support by the government to create sustainable environment for this transition in livelihood for tobacco farmers. Resilience of tobacco economy remains an impediment for this crop switch for majority of the growers.

3. Dynamics of Tobacco Ecosystem in Pakistan

Pakistan remains among top-ten tobacco producers in the world. Tobacco is grown in all provinces of the country, but central KPK remains the production hub of Flue Cured Virginia (FCV) tobacco. It is the main tobacco variety in Pakistan, which is utilized in making cigarettes. FCV variety holds 2/3 share in the total tobacco production of Pakistan. Other tobacco varieties are primarily consumed in the production of smokeless tobacco products, such as Naswar, Gutkha, Pan Masala and others. Tobacco production trends since 2014 are tabulated below:

It is evident from above table that tobacco consumption trend has remained volatile during last 8-years. Available tobacco stock of 119.9 million kilograms in 2021 is sufficient to produce 119.9 billion cigarette sticks. High consumption of smokeless tobacco also needs to be taken into account, as all available raw tobacco is not just utilized in only producing cigarettes. Discussion on smokeless tobacco products will be done later in the section. The Legit Cigarette market of Pakistan is dominated by 2-multinational players, namely Pakistan Tobacco Company (a subsidiary of British American Tobacco) and Philip Morris International. Khattak Tobacco Company is another player with significant market share. Rest of the market share is divided among 58-small and medium companies. All three larger companies are listed at Pakistan Stock Exchange. Their respective market shares along with assets, revenues and net profit are tabulated below:

If above figures are analyzed along with cultivated tobacco trends in Pakistan, then a picture of a robust tobacco economy emerges. There is an anomaly regarding size of illicit cigarette trade in the country. Tobacco industry claims that 37% cigarettes sold in market are of illicit nature, which are majorly non-tax paid or smuggled through different avenues. Whereas per our computation, available stock of tobacco has the potential of producing 58-billion sticks for illicit trade. Among populous countries, Pakistan ranked second on the ratio of illicit cigarettes to total market. Brazil tops the list with illicit cigarettes making up over 53% share of its total market of cigarettes. It will be termed as a dilemma, as Brazil is accorded top position by WHO for high compliance with MPOWER components under FCTC treaty.  

It is clear that big tobacco players are investing billions of rupees in new capacities and new production lines. In 2020, Pakistan Tobacco Company has started the commercial production of tobacco free nicotine pouches through its state of an art plant setup with a cost of USD 10 million. With the installation of new cigarette manufacturing plant, Khattak Tobacco Company has increased its capacity by 23%. 

External trade of tobacco and related products has doubled from USD 45 million in 2017 to USD 90 million in 2021. Major government organizations such as Trade Development Board of Pakistan (TDAP), Planning Commission (PC) and State Bank of Pakistan (SBP) are publishing research reports on tobacco cluster for attracting investment and improvement of its ecosystem. It is happening of despite the fact that Pakistan is FCTC signatory and is bound to curb tobacco usage under the treaty. It may be understood here that despite all the written commitments on tobacco control and even promulgation of related legislation along with stringent regulations, any government in Pakistan has to take into account the economic footprint of tobacco industry. As a low middle income country, it will be treading the path of tobacco reduction cautiously.

Supply side of the prevalent tobacco ecosystem has been elaborated. Now, let us take a look at its demand dynamics. In compliance with FCTC, government of Pakistan conducted first of its kind Global Adult Tobacco Survey (GATS) in 2014. This survey comprehensively covered various facets of tobacco usage and its users in Pakistan. It provides keen insights in the demographic characteristics of tobacco users. In comparison to other such surveys conducted in other parts of the world, GATS in Pakistan missed covering the wealth status of surveyed tobacco users. However, it did include questions on the educational attainment, which can be utilized as proxy for determining economic status.     

We have extrapolated the demographics of tobacco users from the survey year to 2021 at a declining rate in the matrix below:

As highlighted in the Context section that based upon publicly available information on the 2021 market size of 98.2 billion cigarette sticks, the extrapolated prevalence rate seems under-reported. Another GATS is now overdue, which needs to take into account the tobacco market size and its corresponding consumption in the society. Based upon educational attainment, GATS 2014 also offers some insights in the economic demographics of tobacco users in Pakistan. The said survey has segregated educational attainment in 4-categories, as mentioned below:

• No Education
• Primary or less
• Secondary or less
• High School & above

 Demographics based upon educational attainment of tobacco users is tabulated below:

It is evident that illiterate segment makes up overwhelming majority among tobacco users in Pakistan and if we include tobacco users with educational attainment of primary or less, then their collective share goes over ¾ of total tobacco users in Pakistan. It may not be termed as neat classification of lumping users in lower economic category based upon their educational attainment only. With an adult literacy rate of 58% and poverty rate of 22%, a causal linkage between poverty and educational attainment can be cautiously assumed here for Pakistan.

Low literacy of vast majority of tobacco users in Pakistan also impedes their capacity for benefiting from written literature on tobacco threats. It is well elaborated in GATS, 2014 that illiterate and low literate tobacco users are also more resistant to quitting tobacco. They are less aware on the alternates or therapies for tobacco quitting. Surprisingly, their average monthly expenditure on cigarettes is more than their more literate compatriots. It remains in line with market information, where 88% of the cigarette market is dominated by low-cost brands. Low income segments are also likely to remain major buyers of cheap illicit cigarettes, available in ample quantities in the market.

Linkage between poverty and tobacco usage is well established. Tobacco and its products usage remain high among low income segments, which makes up greater part of their disposable income as compared to high income tobacco consumers. Medical treatment cost owing to tobacco-related disease impedes their capacity for social mobility and healthy spending. ENDS and HTPs are another driver for heightened tobacco consumption, especially among younger generation in the society. It will be discussed later in the write-up. 

In the next section, we will review the structure of tobacco control in Pakistan. Its level of compliance with different MPOWER components and determination of ensuing gaps. It will provide the setting for articulating viable tobacco control strategies in the last section.

4. Overview of Existing Tobacco Control Paradigm in Pakistan

     

Even before entering into FCTC, Pakistan has a credible track record on tobacco control. Government has been working on various regulatory initiatives and interventions to reduce tobacco harm among the populace. It has enacted anti-tobacco laws such as Cigarettes (Printing of Warning) Ordinance, 1979 and Prohibition of Smoking & Protection of Non-Smokers Health Ordinance, 2002. Post FCTC ratification, government has proceeded further with stringent tobacco control regulations, especially on banning advertising, promotion and sponsorship. In terms of compliance with MPOWER components, its performance could be termed good as far as promulgation of related regulations is concerned, but implementation on ground remains a challenging proposition. 

Let us first elaborate the country’s compliance performance on MPOWER components in the matrix below:

We have already elaborated the lobbying power of the tobacco industry in the country. It has been able to sustain itself despite all the regulatory onslaught under the FCTC ambit and civil society efforts. With backing of resources, tobacco industry has ample muscle to maneuver the regulatory maze for minimizing its cost to it. Case in point is lack of regulation on ENDS and HTPs in the country. ENDS has been banned in 32-countries, whereas other 78-countries are regulating it. Pakistan is neither regulating ENDS nor it has banned its sale. Sellers of ENDS and HTPs are marketing the products under the guise of harm reduction against combustible cigarettes. In December 2022, government has decided to regulate the sale of HTPs in the country, while treating it as less risky product. 

As a low-middle income country with the 5^th largest population, Pakistan is lagging much behind in the provision of meaningful tobacco cessation support. Government does not have a national level strategy or policy to address the underlying demand for tobacco quitting in a sustainable manner. Existing tobacco cessation ecosystem is geared more towards cigarette smokers, whereas around 40% of tobacco users are involved with smokeless tobacco products in the country. 

There is ample space for improvement in the existing tobacco control paradigm in Pakistan. It is not the matter of ticking the boxes on the paper for compliance. It is a grueling struggle on ground to save lives, with users stuck in vicious circle of tobacco consumption. Country has made progress on eradicating much tobacco footprint in public spaces, but in a tech and connected world journey remains arduous for effective tobacco control. With financial crunch in the government, many of tobacco control public entities are feeling the pinch for proper project development and its implementation on ground. It requires a multi-partite collaboration and coordination between government, multilaterals, civil society, growers, industry and others to overcome this biggest threat of non-communicable disease through tobacco.

In our last section, we will elaborate on the tobacco control strategy followed by an action plan. It will be based upon the findings during our research on the underlying developments around the world in the area of tobacco control. 

5. Tobacco Control Strategies for Effective Implementation

As mentioned in the context section, tobacco control measures could be broadly segregated among:

• Prevention – Purpose of these strategies is to prevent the person from tobacco usage in any form. As envisaged in MPOWER paradigm, enhanced taxation, ban on promotion, restricting sales and smoke free environment will come under preventive measures.
• Protective – These measures focus on creating awareness through information dissemination pertaining to adverse effects of tobacco usage and clamping down on illicit trade of tobacco products. It may include large warnings on the tobacco packaging even promulgating plain packaging, launching national level anti-tobacco mass media campaign and implementation of track and trace system in the industry.
• Cessation – It aims for facilitating tobacco users to quit its usage through multiple tools and measures. It includes both individual and group counseling, quit lines, medication and Nicotine Replacement Therapy (NRT)  

All these strategies will be separately discussed, while taking into account the peculiarities of operating environment in Pakistan, as articulated before. An important factor for consideration remains the presence of over 70% illiterate or low literate and low income base of tobacco users in the country. Any tobacco control strategy has to cater for this bulge to attain a meaningful impact.     

1. Prevention Strategies

Pakistan has already implemented number of measures to restrict tobacco usage in the country. However, their effective implementation remains a challenge for the government. It is also affected due to the tobacco industry lobbying power for restricting the impact of any anti-tobacco measure. 

Imposition of Higher Taxation on Tobacco Products remains a tricky matter. With a 2-tier taxation structure, tobacco industry has been able to park much of their brands in lower tax bracket. Effective tax burden remains low, whereas affordability of cigarettes remains intact to an extent. In the recent tax hike in February 2023, tobacco industry has also raised prices of cigarettes, which have resulted in not much change in tax to retail price ratio. It will result in dip in smoking, but will keep the margins of the tobacco industry intact. For effective tobacco taxation paradigm, government has to cater for factors such as cigarette price, its affordability, tax share and its structure. Government may take a leave from Philippines, which has promulgated 1-tier tobacco taxation despite immense pressure from the industry. It resulted in over tripling in tobacco tax revenues from PhP 32 billion in 2012 to PhP 106 billion in 2017. This rise in revenues also coupled in decline of smoking prevalence rate from 29% to 18%, with larger decline witnessed in low income segment.

Ban on Tobacco Products’ Advertising, Promotion and Sponsorship has remained a pivot in reducing demand specifically among younger segment. Comprehensive ban on tobacco promotion has induced sustained reduction in prevalence rates. Pakistan needs to take a cue from Turkey in imposing effective bans on tobacco promotion with not only incorporating specific clauses in tobacco control laws, but also later proceeded with restricting outreach of tobacco companies through indirect marketing, outline sales and CSR activities. In Pakistan, tobacco industry is creatively using internet to enhance its outreach among its target clientele. Linked with lower taxation on low-priced cigarettes, it becomes perfectly rational for tobacco companies to target low income customer base. With regulatory restrictions on mainstream advertising, promotion for cigarettes is pushed to retail level for their display. Any tobacco control measure has to incorporate restrictions on retail display of tobacco products. 

Smoke Free Environment in public spaces is a requisite for safeguarding citizens from second hand smoke and passive smoking. Pakistan has promulgated restrictive regulations in this regard, but their implementation remains lax. Comprehensive ban on smoking in public spaces include restaurants, indoor & outdoor work places, terraces, schools, universities, sports venues and stadiums. In 2020, South America became the first sub-region to achieve the FCTC mandated goal of creating comprehensive smoke free environment. It provides useful learning to other countries to emulate their successful model of achieving smoke free environment. Enactment of laws is just one part of this overall strategy, governments have been engaged in creating partnerships with non-government organizations, civil society and media for effective implementation. This coalition has to face litigation from their respective tobacco industries in enforcement of these smoke free environment. People from lower socioeconomic strata are more susceptible to second hand smoke owing to their cramped living and working environment. Effective implementation of smoke free regulations for public spaces should be ensured to save this vulnerable segment of the society. 

2. Protective Strategy

In order to protect the citizenry from the adverse effects of tobacco usage, governments usually work upon reducing the quantum of illicit tobacco products in the country, while continuing informing public with mass media campaigns. Regulating cigarette packaging also comes under the ambit of preventive strategies.

Illicit Trading in Tobacco Products has not only garnered attention from the perspective of FCTC paradigm, but is even included in the ambit of money laundering and terror financing. It is prone to money laundering due to its cash intensive nature and low risk for criminal groups in terms detection, seizure, penalties and criminal procedures. Besides smuggling, number of domestic cigarettes manufacturers are also involved in pushing non-tax paid cigarettes in the market. Curbing of this illicit trade remains complex challenge for the government agencies. Putting up high taxation rates on a product, deemed injurious to health, did result in decline of tobacco prevalence rates. However, it has also incentivized criminal elements to exploit loopholes in regulatory jurisdictions for profitable ventures. Government effectiveness in implementing rule of law, curtailing corruption and informality in economy is directly proportional to lowering illicit trading in tobacco products. Protocol to eliminate illicit trade in tobacco products does provide a blueprint of effective implementation plan for curbing flow of this trade. However, only 54 countries have signed and ratified it. It is also evident that availability of cheaper option of illicit tobacco products is inducement for low income groups to continue its usage. Tracking and tracing system of tobacco products is gradually implemented in Pakistan, but it requires an accelerated push along with the multi-pronged coordination strategy to reduce the footprint of illicit tobacco products in sustained manner.

Anti-Tobacco Mass Media Campaigns have provided mixed results in reduction of prevalence rates in both young and adult segments. From early 2010s, a declining trend in such campaigns is witnessed across countries. As per FCTC compliance report, only 45-countries have run national level anti-tobacco mass media campaigns in between 2018-2020. Effectiveness of these campaigns requires continuous follow-ups and spreading outreach. With least exposure to such campaigns among low income segments for long, they become more susceptible to continue usage of tobacco products. These campaigns have to be utilized in combination with other tobacco control measures such as tobacco cessation programs for greater impact.

Health Warnings on Tobacco Packaging has proven to be an effective mean for encouraging tobacco users to quit. From placement of large graphic images of tobacco affected persons on the packaging, governments are progressing towards plain packaging for all cigarette brands. Till 2021, 21-countries have implemented plain packaging regulatory regimes in their jurisdictions, whereas 4-more countries have passed the respective law and related regulations are in process. Despite the vehement opposition to plain packaging from the tobacco industry, gradual progress is continuing unabated. Tobacco companies are famed for their agility to counter regulatory moves to curb tobacco outreach among populace. With increasing number of countries banning advertising, promotion and sponsorship of tobacco products in any form, packaging remains one of the refuge for garnering customers’ attention. Another area of concern is absence of prominent health warning in major chunk of illicit tobacco products available in the market, which enhance vulnerability of low income tobacco users.

3. Cessation Strategy

Globally, 8-million annual deaths can be attributed to tobacco usage. Over 80% of 1.3 billion tobacco users are based in low and middle income countries. In Pakistan, 163,600 yearly deaths could be traced to direct tobacco usage and its second hand smoke. With the under-reported cigarette prevalence rate of 10.4%, population of cigarette smokers stands at over 14.3 million in the country. Over ¾ of these smokers belong to poor segments of the society. In 2019, Pakistan bore a cost of PKR 615 billion owing to tobacco-related diseases and deaths, which makes up over 5-times of the tax revenues generated by tobacco industry. Scientifically, it is an established fact that Nicotine remains highly addictive component of tobacco usage. It means that besides personal will, tobacco quitting requires external support in terms of handholding, guidance and treatment. With all the focus on collective policy measures for tobacco control, its cessation paradigm is lately shaping up for a hybrid coordination between private and public sectors. Health policy makers are facing a challenging proposition for saving vulnerable population sections from charm offensive of tobacco industry under the garb of innovation nicotine addictive products, such as ENDS and HTPs. In the last decade, number of big pharma companies have entered into the tobacco cessation area with the launch of number of products. As per a research study, tobacco quitting rate remains only 4% without cessation assistance. In Pakistan, tobacco quitting ratio remains lowest among illiterate and low literate users, as they are also likely to fall on lower socioeconomic bracket. Interventions under the ambit of tobacco cessation strategy can be broadly segregated among population-wide and pharmacological categories. WHO has made a cessation investment case of $1.68 per capita per year to save 3-million and attain a target of 150 million quitters by 2030.       

Population-wide Interventions are low cost on per capita basis with wider population outreach. It includes counseling in primary healthcare, toll-free quit lines and digital messaging. In Pakistani context, it becomes much productive as majority of tobacco users are illiterate, who are likely to respond more favorably to verbal communication in native languages. With technological advancements in communication, scaling up of these services may not be much difficult proposition. Pakistan has lagged much behind on structured provision of population-wide cessation services. It is matter of fact that off take of government cessation support is picking up slow, but almost all developed countries are bearing some cost of the cessation services. Pakistan may emulate the Turkish model of Smoking Cessation Clinics, a successful outreach venture for effective tobacco quitting. With over 400-such clinics across Turkey, they offer standard tobacco cessation program under the ambit of Turkish Ministry of Health. Major beneficiaries remain the tobacco users for lower socioeconomic strata.

Nicotine Replacement Therapy (NRT) is a market-based remedy for a time-based cessation outcome. Number of pharma and even tobacco companies are involved in the manufacturing of NRT products such as gums, patches, inhalers, lozenges and nasal sprays. With small quantity of nicotine included, NRTs work on gradual curbing of tobacco craving mode. At present, prices of NRT products are on the high in Pakistan with UK-made Nicorette Nicotine gum available at PKR 5,500. Whereas the same product of CIPLA India is available at equivalent PKR 2500. In absence of some sustainable financial / policy support from government and private sector, Pakistan may not be able to scale the NRT intervention. On the line of WHP Cessation Consortium, a coalition of government health organizations, pharma companies, media entities and civil society has to collaborate on structuring a sustained incorporation of NRT accessibility among its tobacco control measures. Jordan provides a replicable model among developing countries of providing comprehensive cessation services including provision of free NRT products

Non-Nicotine Medications are used as pharmacotherapy remedy for overcoming nicotine craving. Bupropion and Varenicline are two US-based Federal Drugs Authority (FDA) approved drugs for tobacco treatment, which are also approved by number health authorities in other countries. These drugs have been included in the national lists of essential drugs in many jurisdictions for facilitating their easy availability and accessibility. Pakistan has not included the two medicines in its government list of essential drugs. These medicines are available over the counter. Government needs to include the two drugs in its list of essential medicines and provide incentives for its import and local manufacturing in order to reduce its cost for poor tobacco users.        

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