Inadequate checks on smokeless tobacco usage in Pakistan: cultural heritage or policy neglect?

The Asian-Eastern Mediterranean block has increased inhabitation of the smokeless tobacco users. Due to geopolitical reasons, Pakistan is one of the countries which is in danger of suffering from future smokeless tobacco-related morbidity and mortality due to weak policy measures. This paper is an overview of smokeless tobacco control measures practised in Pakistan, in comparison to its neighbouring countries sharing similar socio-cultural parameters. Tobacco control reports confined only to smokeless tobacco control were extracted for the region of Southeast Asia and Eastern Mediterranean regions published under World Health Organisation. The selection of countries from each region was based upon the fulfilment of the criterion of sharing common borders with Pakistan and holding a signatory status under framework convention on tobacco control. There is a need to revise existing tobacco control strategy to include smokeless tobacco reforms over pricing, packaging and media communication in Pakistan.


Introduction
Tobacco in all forms is an emerging threat to human survival.The health damaging effects of tobacco include premature or still births, increased dependency, adverse cardiovascular events (ACEs) and various forms of cancers which have been widely documented in literature. 1,2This is alarming for the developing countries which are home to most of world tobacco users. 3Furthermore, the political instability, receding economy and prevailing poverty has forced people to opt for unhealthy choices to relieve stresses and hunger.Since smokeless tobacco (ST ) products are economical in this matter, hence, they remain th e pre fe rre d choice for p eo ple in g ene ral.
][6][7][8] Not only these but predisposing factors such as accessibility, purchase power, weak legislation and delayed implementation of existing policies provoke many of the never users at risk of experimentation.Experts have estimated that if prompt measures are not enforced, it might kill 8 million people in the next decade. 9nsidering the gravity of the problem and the observed epidemic shift, a public health treaty named World Health Organisation Framework Convention on Tobacco Control (WHO FCTC) was signed globally to protect people from adverse social, environmental, economic and health consequences of tobacco. 10Under this convention, tobacco control indicators were set with timely monitoring of member states.
Pakistan ratified this convention in 2004.Since then a number of measures have been adopted in terms of (smoked) tobacco control such as efforts to control its point-of-sale promotion, sponsorship, advertisements on mass media, smoke-free environments and sale of the products.However, the devastating effects of ST has received little attention in this regard. 11,12The current review was planned to study ST policies in Pakistan in the light Monitor, Protect, Offer help, Warn, Enforce bans and Raise tax (MPOWER) criterion.

Methods
The situation analysis was conducted to evaluate the progress of Pakistan in terms of ST control and to compare it with the neighbouring countries.A literature search was done to assess the improvement in MPOWER indicators set under FCTC in selected countries.The selection of neighbouring countries was based upon geographical landmarks sharing common borders with Pakistan and their membership to the global tobacco control treaty (Figure).In order to monitor the tobacco policies in Pakistan, online government documents were further assessed for demand reduction strategies, such as tax measures, packaging or labelling of products and media strategies, as endorsed in articles 6-12 of WHO-FCTC.The findings of these and the announcements made by Ministry of Health were closely monitored by another investigator between January 2017 and May 2018.

Situation analysis
In Asia, ST products are the major causative agents responsible for tobacco-associated morbidity and mortality. 13Each year, over a million deaths are caused by tobacco-associated diseases. 14In India and Pakistan, 8-10 % of the non-communicable disease (NCD) proclaimed deaths are caused by cancers. 15Among these, oral cancer remains the most common reason.It has been estimated that the risk of developing head and neck cancer is two-fold high in tobacco chewers than in the non-chewers. 16,17er the last decade, smoked tobacco users have switched to alternative forms and ST is one of them.9][20][21] Interestingly, against an observed decline in the global usage of smoked tobacco products, the ST users have increased in countries such as India and Bangladesh at a positive difference of 6% and 3% respectively. 22like India, Pakistan reports fairly high number of current ST users with an increased propensity in males.A large majority of the tobacco users (inclusive of ST component) are clinging to use it within 30 minutes of their bed-rise. 23his dependency phenomenon is relatively higher for (ST) products in comparison to smoked tobacco. 24In Pakistan, current ST use in adults and youths is 7.7% and 5.3% which, according to national surveys, is more common in rural areas. 23,25Among the different types of ST products, people from the rural sector frequently used Naswar whereas in the urban segment betel quid (Pan) with tobacco is popular.
Although our estimates are slightly lower than our immediate neighbours [26][27][28][29] (Table 1A), our borders are open to illegal smuggling via indirect routes evading the c ou nt r y -s p e c if i c r e g u l a t o r y restrictions, making it one of the greatest f o r t h c o m i n g c h a l l e n g e s f o r Pakistan to face. 30,31eing in the vicinity of conflict-prone region, its impact on the    Records over smoked tobacco were excluded average income of a person, the vulnerability of economic stress-induced abuse remains a future concern.Moreover, Pakistanis ars still fighting to shed off endemic polio virus, and, as suc, the control of ST products remains at the bottom of prioritised health agenda.Furthermore, political unrest over the past decades is a major impediment in the conduct of national level surveys to yield updated numbers to align policies accordingly.Unfortunately, no such predictions have been made precisely in case of Pakistan.

Policy Measures Pricing and Tax
In view of the demand reduction side for ST policy-making, tax is being imposed on tobacco products either by ad valorem or specific tax.Interestingly, ST in low-income groups is much affordable for its cheaper price even in existing tax measures 32 (Table 1B).Likewise for cigarettes, a 4% rise in the excise tax is anticipated to reduce the demand in 3 million smokers, preventing an additional million from being future smokers and will supplement a revenue of USD126 million. 14Unfortunately, no such speculations could be made for ST products due to nonuniformity in their production, packaging, pricing and missing tax measures.
In the beginning of 2018 in Pakistan, the ban on Gutka and detention of areca containers has further promoted illicit trade in forbidden and informal ways. 35Local vendors are selling them illegally at designated sites despite penalty in monetary terms.Unfortunately these bans do not imply at local points of sales.Apart from this, surrogate advertisements are broadcast at other social media platforms such as cable television channel network which often is unregulated.
Produc t labelling and packaging: a) Presence of warnings on the packaging: One of the policy measure recommended by FCTC is to reduce the demand of the product by informing people about the hazards of consumption through warning labels.In this matter, India is leading us by observing 85% of the ST packaging to cover texto-graphic health warnings.Bangladesh and Iran are not far in this marathon by designating a 50% display of front and rear surfaces for health warning texto-graphic (Table 2).In spite of the several pledges to mandate the printing of these warning messages, Pakistan is lacking in terms of implementation.

b) Labelling of the constituents:
In Pakistan, the chemical composition of ST products cannot be determined due to non-homogeneity in its manufacturing and packaging.According to a recent biochemical assessment of imported ST products, the nicotine content was reported to range between 0.39 mg/g and 20 mg/g which in some of the formulations surged to a level higher than 40mg/g. 36This might vary in other (locally sold) unregulated formulations which might carry unidentified ingredients intermingled to appeal the taste buds.Hence, to measure the mutagenic potential of such ingredients, laboratory testing of all available forms of ST is warranted.In addition to this, public disclosure of these carcinogens must be ensured.

Media Awareness
All member states are further required to create public awareness among people in general about the aftermath of tobacco.Two mass media campaigns named "sponge", featuring cancerous tar absorbed by smokers lung, 37 and "Tobacco is hollowing you out", about the harmful illnesses caused by tobacco, were aired in Pakistan. 38,39Although Pakistan has shown compliance with mass media indicators set under the convention (Table 3  specificity of these campaigns against the relative burden of Gutka and sweetened areca hazards is entirely missing.In this regard, India has set an example by implementing a 30-second media campaign known as SURGEON, in collaboration with World Lung Foundation, featuring personal stories of patients suffering from oral cancers. 40lso, there is timely evaluation of the impact of designated campaigns to see their cost-effectiveness. 4 0 , 41

Recommendations
The policy makers must conduct national level surveys to estimate the inflation of ST users and frame policies accordingly; qualitative and quantitative inspection must be do on all available ST products inclusive of their biochemical assessments which shall be made public; ST-associated products, such as areca nut, must be included in the policy framework; packaging reforms, such as presence of effective warning labels, must be regulated and checked with periodic intervals; tax reforms are needed to raise the threshold of the affordability index of a street user; penalty be imposed on indirect advertisement of ST products by local television cable operators and its reinforcement by the Pakistan Electronic Media Regulatory Authority (PEMRA); and capacitybuilding must be done to train health professionals / doctors / dentists / pharmacists / nurses / paramedical staff about cessation strategies and to ensure low-cost services at the primary care level.

Conclusion
Despite being a signatory to the global tobacco control treaty, there is an inadequacy in the demand reduction strategy of ST products in Pakistan.Hence, reforms are needed to comply with pledges made under WHO-FCTC.

Table -
1A: Smokeless tobacco consumption across selected countries of EMR and SEAR.

Table -
1B: Forms of smokeless tobacco and associated products available in Pakistan.
Figure: Selection of countries for the review of ST control measures.EMR= Eastern Mediterranean Region; Pakistan, Iran and Afghanistan SEAR= Southeast Asian Region; India and Bangladesh ), the Inadequate checks onsmokeless tobacco usage in Pakistan: cultural heritage......

Table - 2
: Packaging of Smokeless tobacco (ST) product in the neighbouring countries of Pakistan.

Table - 3
: Smokeless tobacco consumption across selected countries of EMR and SEAR.