Introduction
The tobacco burden in South-East Asia Region (SEAR) is one of the highest among WHO regions.[1] The widespread use of many forms of tobacco, including smokeless tobacco (SLT), complicates efforts to implement effective tobacco control initiatives,[2] Despite these challenges, each country in SEAR has nevertheless taken important steps to combat the tobacco epidemic. Ten out of eleven countries of the region have ratified the WHO Framework Convention on Tobacco Control (WHO FCTC).[3] Although Indonesia is not yet a party to the convention, it has recently undertaken initiatives at the sub-national level.[4]
It is important to recognize that several countries in SEAR have implemented measures that can be classified as "best practices" for tobacco control according to WHO FCTC and its guidelines. These "best practices" are evidence-based, practical, and are the most effect measures to ultimately reduce tobacco consumption. This article will highlight these best practices so that other countries can learn from these examples.
Reducing supply
Reducing the supply of tobacco products
The WHO FCTC includes measures to reduce both supply and demand for tobacco. A unique example in SEAR of supply-reduction comes from Bhutan. Since 2004, Bhutan has banned the sale of tobacco products and any form of cultivation, manufacture, sale or distribution of tobacco/tobacco products.[5] Individuals can bring in a limited quantify of tobacco for personal consumption from other countries, which is subject to 100% sales tax and customs duty. As of 2012, the maximum monthly quantity for personal consumption was 300 cigarettes. Strict fines are imposed on anyone found in possession of tobacco products for which they have not paid tax.[6]
Reducing the supply of smokeless tobacco through banning gutka
In many SEAR countries, SLT use is high among both men and women. In India, nearly 90% of oral cancer is caused by SLT use, and it has also been found to contribute to cardiovascular diseases.[27] A commonly used form of SLT in SEAR is gutka, a preparation of crushed areca nut, tobacco, catechu, lime and flavouring agents. Gutka is widely sold across India in small, low-cost individual packets.[8]
In 2010, the Supreme Court banned the use of plastics in gutka packaging after determining it was an environmental hazard. This decision, upheld in March 2011, paved the way for banning gutka itself, since most gutka is sold in plastic sachets.[9] Government and civil society came together to plan an approach for banning gutka for health reasons. The Supreme Court also directed Government of India (GOI) to undertake an analysis on the contents and harmful effects of SLT. The Ministry of Health and Family Welfare (MoHFW) in consultation with experts prepared a comprehensive report on SLT and areca nut and submitted it to Supreme Court in February 2011. In April 2011, MoHFW and WHO organized a national consultation on SLT which recommended progressive restrictions, including bans on all SLT including gutka.[10]
A firm basis for banning gutka was established when Supreme Court ruled in 2004 that products such as gutka and pan masala are indeed food products. This allowed the Government of India (GOI) to enact regulation 2.3.4 under the 2006 food safety and standards act (FSSA). Regulation 2.3.4 states that "product not to contain any substance which may be injurious to health: Tobacco and nicotine shall not be used as ingredients in any food products," thereby banning sale of any food product containing tobacco and nicotine such as gutka. To support implementation of these regulations, MoHFW sent letters to state governments to initiate action at their end.[11]
Civil society has played a catalytic role in advocacy to create support for implementation of the FSSAI regulations. Advocacy by voices of tobacco victims (VOTV), comprised of individuals suffering from the visible effects of tobacco use, provided a much-needed impetus. Directors of all regional cancer centers also sent letters to the Prime Minister seeking a gutka ban. Political support was garnered through Chief Ministers of 11 states and hundreds of other leaders signing pledges to ban gutka. Members of legislative assemblies were sensitized by VOTV on the harms of gutka, and sustained media coverage generated.[12]
The state of Madhya Pradesh became the first state to issue orders to implement regulation 2.3.4, thereby banning sale and storage of gutka from April 2012, and has since cancelled licenses of gutka manufacturers and confiscated vast quantities of gutka. As of August 2012, ten states have banned gutka and numerous others are considering a ban. In some states, the ban also extends to pan masala. Further, three High Courts have dismissed petitions challenging the ban and have ruled in favor of the implementation order.[13]
Measures to ensure effective enforcement of the ban are crucial. Enforcement efforts in states first adopting the ban are being studied so that lessons can be shared. There is a need to effectively defend legal challenges, discuss next steps and develop strategies for fully implementing the ban across India.
In order to prevent the uptake of SLT use, countries that do not manufacture the product can take measures for a complete ban on import of SLT as was implemented by Thailand in 1992 and recently by Bhutan.[14]
Reducing supply of tobacco through alternative crops
Tobacco growing is a health risk for farmers and also detrimental to the environment. It requires large amounts of chemical fertilizer and pesticides causing pollution of the ecosystem, soil depletion, and is a major cause of deforestation.[14] Tobacco growing has also kept many families in a vicious cycle of poverty. Tobacco-producing countries including Bangladesh, India, and Indonesia are exploring ways to help tobacco farmers switch to alternative crops.
In Bangladesh, a Non Governmental Organization (NGO) called Policy Research for Development Alternatives (UBINIG) has conducted extensive crop substitution research. Since 2009, this project has helped over 500 farmers shift from tobacco to food production by partnering with an NGO. This movement is led by farming communities practicing biodiversity-based ecological agriculture. A major component of the crop substitution initiative centered on mixed cropping, crop rotation, and no pesticides, herbicides or chemical fertilizers.[15]
Case illustration
The feasibility of successful model of alternative crop can be illustrated from Bangladesh. In shifting out of tobacco this particular farmer shifted from chemical fertilizers and pesticides to ecological agriculture. The only initial expenditure involved was for seeds and natural compost. In the first four months, the farmer harvested potatoes, beans, radish, and coriander leaves with his net earnings twice as much as from tobacco. The next harvest was equally successful financially and the family also now has food security. This initiative is being scaled-up by an NGO.[15]
Bangladesh law prohibits bank loans for tobacco cultivation, bans subsidies on fertilizer to tobacco farms, and stipulates that the government shall provide easy-term loans to cultivate alternate crops. To scale-up crop substitution nationally, several interventions are still needed including supply of food crop seeds. However, this model project shows the potential for farmers shifting from tobacco with positive gains for their income, food security and the environment.
Demand reduction measures
Protection from exposure to tobacco smoke
There is no safe level of exposure to second-hand smoke (SHS), and even brief exposure can cause serious damage including heart disease, respiratory illness, and lung and other cancers. Each year, approximately 600,000 non-smokers are killed by exposure to SHS.[16] Only a total ban on smoking in all indoor public places can protect people from the harms of SHS.
Many countries in SEAR have implemented national level provisions mandating smoke free environments. Thailand has achieved best practice status through a step-by-step process, beginning in 1992 and gradually making additional venues smoke free. In 2010, smoking was banned in all indoor public and workplaces and open air public places such as markets. The only indoor venue where smoking is currently allowed is in designated smoking rooms (DSRs) in international airports.[17]
Smoke-free policy at sub-national level
Other countries have made progress through a sub-national approach, such as the Maldives, where several islands and atolls were declared smoke-free. In India, the smoke free rules were revised in 2008 to make all indoor public places smoke-free, although DSRs are allowed in limited circumstances. Implementation and enforcement in India has achieved great success through a sub-national approach with an increasing number of cities, districts and villages being declared smoke-free. Even before the revised smoke-free rules came into effect, Chandigarh was first city to be declared smoke free in 2007.[18]
Although national legislation is still weak, Indonesia has achieved success with local governments and NGOs working together to focus on sub-national smoke-free initiatives. Indonesia's 2009 health law serves as the basis for expansion of smoke-free policies sub-nationally. A 2011 joint ministerial decree by MOH and Ministry of Home Affairs provides guidance for sub-national smoke-free implementation. In 2010-11, several concerted actions took place including a series of workshops on smoke-free implementation. In 2011, a Mayors' alliance was launched to accelerate local smoke-free actions. Many of the cities going smoke-free also issued regulations to ban tobacco advertising in outdoor media.[19]
In Padang Panjang, the integration of smoke-free initiatives with its healthy cities project was one strategy that helped its success. There was also a total ban on smoking in the Mayor's office and in events involving the Mayor. Community leaders working together advocated smoke-free lifestyles. Media was engaged as a partner, writing articles highlighting the importance of tobacco control. Local radio stations discussed the harms of tobacco and instituted a policy refusing cigarette advertising. As of August 2012, Indonesia had seven cities with 100% smoke-free local law/regulation, five cities with smoke-free law/regulation allowing DSRs in work places, and four Provinces adopting provincial smoke-free laws.[20] These achievements are particularly significant considering the challenges faced in Indonesia including high smoking rates and strong tobacco industry influence.
Warn people about the dangers of tobacco
Many countries in the region have taken important steps to warn people of the dangers of tobacco use. These measures have included the use of strong pictorial health warnings as well as comprehensive hard-hitting mass media campaigns.
Health warnings on tobacco products are a cost-effect means to provide information on the dangers of tobacco use and exposure to SHS. However, text-only warnings have limitations among less literate people. Graphic health warnings can reach these populations and are shown to have greater impact on motivating tobacco users to quit.[21]
Thailand has mandated graphic health warnings since 2005, starting with 50% of both sides. In 2010, the third set of ten rotating pictorial health warnings was implemented covering 55% of the front and back of cigarette packs, with five rotating pictorial warnings on cigars covering 50% of the packet. Two pictorial warnings on roll-your-own cigarettes will soon be implemented. Since 2006, a warning of toxic substances in cigarette emissions is required on 50% of both sides of the lesser size panel of cigarette packs. In 2010, the national quitline number was required to be printed on the pack.[17]
Nepal has recently passed legislation mandating pictorial warnings covering 75% of the front and back of all tobacco products, including SLT.[22] In India, pictorial health warnings were implemented in 2009. From December 2011, warnings were strengthened, particularly for SLT products. However, the warning is required on only 40% of one side, which is not yet WHO FCTC compliant.[23]
Mass media campaign
An intensive, well-funded and sustained national mass media campaign to build awareness of the health effects of tobacco is necessary to advance tobacco control and change social norms. In 2007-08, GOI launched the National Tobacco Control Programme (NTCP), with national-level mass media campaigns as an important component.[24] According to a WHO report, India is one of the few countries to have a dedicated budget for tobacco control mass media campaigns.[25]
Since 2008, at least three national campaigns on television, radio and print have been conducted in India each year. Most were aired with technical support from World Lung Foundation (WLF) using an evidence approach including vigorous pre testing, and were aired in multiple languages across India. For cost-efficiency, these campaigns included spots originally developed in other countries and adapted for use in India. For example, the "Sponge" campaign, depicting the shocking amount of tar inside smokers' lungs was originally aired in 2009. This campaign was so successful that MoHFW ran it for a month around World No-Tobacco Day in 2010 and 2011.
Case illustration
In 2009, in collaboration with GOI, WLF initiated a sustained mass media campaign on the harms of SLT. One spot features a 24 year old male, representing the growing number of young men using SLT. The campaign was filmed at the hospital where he was being treated. The television campaign was supplemented by a website and SMS campaign. This highly impactful campaign has also been used to successfully advocate for a gutka ban.[26]
WLF also provided support for India's campaign on the harms of bidis, including its cardiovascular effects. It graphically depicts a bidi smoker suffering a heart attack, describes the suffering of his family, and encourages bidi smokers to quit.[24] WLF also helped support sub-national media campaigns to reinforce the national efforts.
WLF is helping MoHFW develop an evidence-based communication strategy that includes conducting formative research, developing and adapting effective spots, creating earned media, and monitoring/evaluating. Government of India (GOI) has set a precedent in SEAR in its commitment to substantial and sustained funding for high quality media campaigns. Although other countries in SEAR have also implemented hard hitting campaigns, sustained funding will be needed to achieve high levels of awareness and behaviour change.
Voice of Tobacco Victims campaign
Voice of Tobacco Victims (VoTV) is a collaborative effort initiated by a senior surgeon at Tata Memorial Hospital, who was concerned by the growing number of young patients suffering from oral cancer due to SLT. He organized VoTV so that patients and their families could share their heart-wrenching stories with the media and policy makers. The victims, many of whom are disfigured by their disease, present the impact of tobacco on their lives, and warn others against the dangers of tobacco, particularly SLT. They also advocate for adoption and implementation of effective tobacco control policies. The physicians/tobacco control advocates provide evidence on the effectiveness of these policies.[27]
VoTV has demonstrated its ability to create an emotional connection with policy makers and has repeatedly demonstrated its ability to propel policy makers to action. VoTV and patrons have lobbied with members of parliament, ministers, and other policy makers, and sensitized media and the public on the consequences of tobacco use on them and their families. This has raised the profile of SLT and has created support for a gutka ban.[27]
VoTV provides the "face of tobacco control" reminding policy makers of the need to take effective measures to prevent the disease and suffering caused by tobacco. Based on the success of VoTV in India, campaign for tobacco free kids is supporting similar efforts in Bangladesh and Indonesia.
Comprehensive bans on tobacco advertising, promotion and sponsorship
WHO FCTC calls for a comprehensive ban on all tobacco advertising, promotion and sponsorship (TAPS). In SEAR, Bangladesh, India, Myanmar, Bhutan, and Sri Lanka have fairly comprehensive bans.[25] However, in most of these countries, advertising is still allowed at point-of-sale. Thailand's 1992 legislation bans most forms of TAPS, including brand stretching. In 2005, Thailand achieved best practice status on TAPS when MOH issued a notification banning display of signs, logos, and the cigarette package itself at point-of-sale. Despite these significant achievements, there are still some gaps that Thailand is looking to close including cross border advertising, internet sales, and corporate social responsibility programmes by the tobacco industry.[28]
Reducing tobacco imagery in movies
There is substantial evidence linking exposure to tobacco imagery in movies and youth tobacco initiation.[29] In recognition of this, WHO FCTC Article 13 Guidelines recommend specific measures to limit movie smoking. Thus far, India is the only country with comprehensive legislation to reduce tobacco imagery in movies as part of a ban on TAPS.
India's tobacco control legislation, COTPA, includes a comprehensive ban on TAPS. However, as other forms of TAPS were banned, tobacco imagery in movies significantly increased. To address this, COTPA's rules were amended in 2005, resulting in court challenges and further consultation with Ministry of Information and Broadcasting (MoIB) which was responsible for implementing the rules.[29] MoHFW issued new rules, effective from 14 November 2011. The rules have been further amended and notified in September, 2012. The revised rules strengthen its implementation by putting the onus of implementation on the owner or manager of cinema halls and broadcasters of television programmes. The central board of film certification is responsible for enforcement of these rules.[30] Key provisions to the rules include:
The health spots and disclaimers mandated under the rules have been prepared by the ministry of health and family welfare and provided to the central board of film certification for implementation.
- No tobacco product placement/tobacco brand names shown
- Close-ups of tobacco products/packages prohibited.
- Promotional materials shall not depict tobacco use.
- Old films and television programme displaying tobacco products or its use shall have
- A 30 second anti-tobacco spots at beginning and middle of films and television programmes
- A health warning scroll during the period of display of the tobacco products or their use in the television programmes
- New films/television programmes displaying tobacco products or its use shall have
- A strong editorial justification
- A 30 second anti-tobacco spots at beginning and middle of film/TV Programme
- A disclaimer of minimum 20 seconds on ill effects of tobacco use at beginning and middle of film/TV Programme
- Anti-tobacco health warning as a prominent static message at the bottom of the screen.
Comments and Conclusion
Tobacco use has been taking a huge toll on the health and economic welfare of SEAR countries. In order to combat the tobacco epidemic, a multi-faceted approach is needed using evidence based strategies to reduce both the supply and the demand for tobacco products. In a time of scarce resources and competing priorities, countries in SEAR must ensure that the most effective and cost-efficient measures, in line with the WHO FCTC provisions, are implemented.
It is heartening to note that although much work still needs to be done, countries in SEAR, have nevertheless taken strong and often innovative tobacco control measures. These best practices in some instances have set global precedents. It is hoped that other countries, in SEAR as well as around the world can learn from these examples and as appropriate, adapt these measures to their own specific cultural, social and political realities. Countries in SEAR are encouraged to learn from best practice examples from other Regions. Through this strategy, the pace of tobacco control can be accelerated, resulting in reduced tobacco consumption and the ensuing reduction in tobacco-related mortality and morbidity.
Source of Support:
Nil
Conflict of Interest:
None declared.
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