Hitting roadblocks to tobacco endgame

With one person dying every six seconds from a tobacco-related disease -- almost 5.4 million deaths per year of which more than 600,000 are of non-smokers due to secondhand smoke-- the tobacco epidemic is a global public health threat. If current trends continue, by 2030 nearly 8 million people are expected to die annually from tobacco-related illnesses. More than 80% of these preventable deaths will be among people living in low-and middle-income countries.

Health consequences of tobacco use

In early 2014, the U.S. Surgeon General released a report which expanded the list of smoking-related illnesses. While lung cancer and heart disease remain the mainstays, diabetes, colorectal and liver cancers, ectopic pregnancy and TB have been added.

Professor (Dr) Rishi Sethi of the Cardiology Department of King George’s Medical University said that in his hospital the daily average OPD patient load for cardiovascular diseases (CVDs) is growing annually by 25%-30%. A significant number of these patients are below 40 years, and most have no conventional risk factor such as diabetes or hypertension. But tobacco use is common in all his patients. Thus tobacco is an important, even though preventable, risk factor for cardiovascular diseases—the no.1 killer disease today.

According to Dr Sethi, "Chemicals in cigarette smoke cause cells in the blood vessels’ lining to become swollen and inflamed. This narrows the blood vessels and can lead to many CVDs like coronary heart disease, stroke, peripheral arterial disease, etc. Even as it is not known exactly which smokers will develop CVD, the best thing for all smokers to do for their heart is to quit. Within one year of quitting, the risk of heart attack drops dramatically, and even those who have already had a heart attack can cut their risk of having another one if they quit."

Tobacco: common risk factor for killer NCDs

At the last World Conference on Tobacco or Health held in March 2015 in Abu Dhabi, Jose Luis Castro, Executive Director of the International Union Against Tuberculosis and Lung Disease, (The Union) stressed upon focusing on the impact of tobacco control on non-communicable diseases (NCDs). It was for the first time that a world conference on tobacco control discussed at length not only about tobacco control policies but also about NCDs. Jose said that, “Link between tobacco use and NCDs is clearly established. This is an important year as we are going to adopt the sustainable development goals (SDGs) in September 2015. So discussions addressing the risk factors for NCDs, of which tobacco use is a major one, are important for setting the global agenda for the next 15 years. Tobacco affects not only the health but also the economic development of countries. Tobacco industry interference in the political systems also destabilizes the efforts of governments to ensure health of its citizens.”

Stopping illicit tobacco trade

World No Tobacco Day, organised by the World Health Organization (WHO) every 31st May since 1988, highlights the health risks of tobacco use and advocates for effective policies to reduce consumption of this deadly poison.This year’s theme calls on countries to work together for ending the illicit trade of tobacco products, by promoting the ratification of, accession to and use of the Protocol to Eliminate Illicit Trade in Tobacco Products by all Parties to the WHO Framework Convention on Tobacco Control (WHO FCTC).

Illicit trade of tobacco products is a major concern in almost all countries. WHO estimates that the illicit tobacco market accounts for as much as one in every 10 cigarettes consumed globally.The European Commission estimates that illicit trade in cigarettes costs the EU and their Member States over €10 billion annually in lost tax and customs revenue.

Challenges in controlling the tobacco epidemic

Dr Ehsan Latif, Director of Tobacco Control department at The Union, is worried at the challenges posed by the tobacco industry to the global efforts to control the tobacco epidemic. He says that, “Tobacco companies spend billions of dollars every year on tobacco advertising, promotion and sponsorship. A WHO report says that evidence from tobacco industry documents reveals that tobacco companies have operated for many years with the deliberate purpose of subverting the efforts of the WHO to control tobacco use. They participate in Corporate Social Responsibility activities and influence politicians to promote their brands and drive profits. As per the 5th edition of Tobacco Atlas 2015, the tobacco industry has 161 lobbyists working in the European Parliament. In the US, over USD 26 million were spent on tobacco lobbying in 2012 with 23 Tobacco companies employing 174 lobbyists”.

Other challenges cited by Dr Latif are: illicit trade of tobacco products; lack of established tobacco control infrastructures in low/middle income countries; non linking of tobacco control with development agendas of the country; introduction of new products that use tobacco or nicotine (like e-cigarettes, waterpipes/ shisha/ hookah). Dr Latif laments that, “the tobacco industry is promoting e-cigarettes in a big way to ‘bring back the chic attitude, the sexiness in smoking’ as admitted by Oliver Girard, CEO of Smarty Q E-cigarettes.”

Jose too cautioned against e-cigarettes. “E-cigarette companies are using the same tactics that the conventional cigarette industry used 50 years ago saying that cigarettes were not harmful for human health. They are sleek, and are socially acceptable. The industry is cleverly advertising them so that there is enticement for everyone, especially for those who are first time users. They come in numerous flavours like pina colada, strawberry, etc. as if one were ordering a smoothie and not an E-cigarette! Some European countries have banned/ regulated them. But the trend of their increasing use is dangerous and we have to be very vigilant. Across the street of my office in Paris, two e-cigarettes shops were opened last year, perhaps due to proximity of the area to the University of Paris, making it very convenient for the students to buy them.”

“Then again shisha/ water pipes/ hookahs are equally harmful but gaining popularity. A study in India found that in 70%-80% of people who had smoked hookahs, nicotine content in blood was very high. Hookah bars target mainly young people and it is often a group activity that is being romanticized-- attracting and beckoning young people to enjoy (same way as they enjoy perhaps coca cola)”.

“We have to be not only very vigilant but also send out correct public health messages giving correct information about these new products to young people. We also have to advocate for governments to regulate them”, he said.

Emerging tobacco control measures

Professor Lisa A Bero of the University of Sydney told Citizen News Service (CNS) that, “Individual based interventions do not work as well as population based policy interventions in tobacco control. So we need a whole package of population based interventions. When we focused on individual smoking cessation we only got so far. But once we moved to restricting smoking areas, to second hand smoke, to tax increases, advertising restrictions, we have witnessed a huge decline in tobacco use. Plain packaging in Australia seems to be working very well—there is data to support it.” (Australia banned branding from all tobacco packs and introduced plain packaging to reduce the appeal of cigarettes in 2013. It also featured strong graphic health warnings. A 12.8% decrease in tobacco consumption was recorded within two years of implementing this plain packaging legislation. Now the UK, Ireland, France and several other countries have committed to introducing plain packaging to reduce the appeal of cigarettes).

In the opinion of Dr Tara Singh Bam, The Union's Technical Advisor on Tobacco Control to Nepal and Indonesia, “Cost effective interventions like large graphic images called pictorial health warnings (PHW) on tobacco packs encourage smokers to quit; motivate youth not to start smoking; re-convince ex users to remain smoke-free and build public awareness”. However, many countries still lack effective tobacco pack warnings, and some have none at all, what with the tobacco industry bending backwards to sabotage their proper implementation.

Dr Bam also finds PHW an effective intervention in eliminating illicit tobacco trade. Illegal trade of tobacco products helps to increase use of tobacco by bringing down their cost thus making them more accessible especially to youth and adults from low-income groups. Moreover, such illicit products also mislead young tobacco users by not displaying health/pictorial warnings. My first brush with illicit trade was two years ago in my home city of Lucknow, when I saw a customer purchase an Indonesian brand of cigarette (sans any pictorial warning) from a roadside kiosk.

Illicit trade also takes tax revenue away from governments, which could have otherwise been spent on the provision of public services. Tobacco companies have been known to use loopholes in tobacco control laws and are said to encourage illicit trade of tobacco products. Illicit tobacco trade thus abets tobacco usage at the cost of human health, besides strengthening corruption and weakening good governance. It undermines tobacco control policies and also leads to significant revenue losses. It is time we realized that the elimination of all forms of illicit trade, including smuggling and illegal manufacturing of cigarettes as well as smokeless tobacco products, should be an essential component of tobacco control.

Shobha Shukla, Citizen News Service - CNS

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