Musaddique Hussain, Abdul Majeed, Imran Imran, Muhammad Fawad Rasool, Ikhlaq Hussain, Qasim Barkat, Ximei Wu
Tobacco use continues to grow in Pakistan due to lack of awareness about its dangers, low prices, aggressive tobacco industry marketing efforts and steady population growth. According to Dr. Abid Saeed Nima, WHO’s acting chief in Pakistan, new estimates show that tobacco kills over 200,000 people annually in the country. In 2002, the Pakistan government introduced the Prohibition of Smoking and Protection of Non-smokers Health Ordinance, and it ratified the WHO Framework Convention on Tobacco Control (FCTC) in 2005. Despite this early progress, today much is still needed to ensure tobacco control is properly implemented and enforced.
The overall prevalence of tobacco use among adults increased slightly from 19% in 2003-04 to 19.7% in 2013-14. Among males, tobacco use prevalence increased from 31%to 35.6%, and from 6% to 8.7% among females. Similarly, the Global Youth Tobacco Survey (GYTS), a school-based survey of students aged 13 to 15 years, showed an increase in tobacco use from 10.1% in 2003 to 10.7% in 2013. Use among boys increased from 12.4% to 13.3%, while among girls there was a slight decrease from 7.5% to 6.6%. Of significant concern is the high proportion of female smokers among youth (1 female smoker for every 2 male smokers), compared to adults (1 female smoker for every 5 male smokers).
Pakistan now has more young people than it has ever had, and growth is forecasted to continue until at least 2050, providing a lucrative growing market for both cigarettes and shisha. A recent study ‘Big Tobacco, Tiny Targets’ revealed how tobacco advertising, product displays and sales around primary and secondary schools by the tobacco industry carefully target youth, specifically girls. Children can be seen buying single cigarettes from convenience stores. The sale of single cigarettes is strictly prohibited according to Pakistan’s tobacco control legislation, however the rule is rarely enforced.
The growing popularity and cultural and social acceptability of water-pipe smoking, (also known as shisha/sheesha and hookah) among young people and women has led to a rapid increase in the number of shisha cafes in Pakistan. In addition to direct risks to smokers, shisha smoke poses a serious risk for non-smokers, as it emits smoke pollution from both tobacco and the heat source. Overall, 3% of Pakistani adults (4.7% of male, 1.1% of female) smoke shisha/hookah. However, water-pipe use among students is much higher. Nationally, 12.6% of Pakistani students have ever smoked shisha; in Balochistan province, the figure is 19.1%. In compliance with an order passed by the Supreme Court of Pakistan, the Ministry of National Health Services, Regulations and Coordination (NHSRC) imposed a complete blanket ban on the shisha business to halt the trend of shisha smoking in young people. Smoking apparatus were confiscated along with tobacco, and smokers were apprehended; however, the implementation of this ban was far too weak.
A 2015 study found unexpectedly high use of chewing tobacco among women in Pakistan’s largest city, Karachi, which also has smoking rates. The survey of 19,325 people in the city revealed that 54% of households had at least one family member using tobacco in some form. Chewable tobacco use in women has risen to 42% and smoking to 18% among women aged 30 to 45. This unchecked increase is likely due to easy access to tobacco products and the absence of pictorial health warnings on smokeless tobacco products.
Exposure to tobacco smoke pollution remains unacceptably high. The 2014 Global Adult Tobacco Smoke survey found 43.3% of adults are exposed to second-hand smoke at home, 46% in universities, 72.5% in workplaces, 76.2% on public transport and 86% in restaurants. Among youth aged 13-15, 21% are regularly exposed to second-hand smoke at home, and 37.8% are exposed in public places. Sixteen years after the 2002 ordinance declaring restaurants, hotels, malls, educational institutions, hospitals, waiting rooms and transport including buses and railways as smoke-free public places came into force, smoking continues due to low public awareness of the law. Moreover, there is no standardized protocol for issuing warnings and fines, or for monitoring establishments and closing down repeat offenders. Taking action against these establishments is a challenging task because it requires the consent of a multi-member committee that includes, among others, the Ministry of Health, Ministry of Tourism, and the Pakistan Restaurant and Hotel Association.
The WHO has called upon Pakistan’s new government, Pakistan Tehreek-e-Insaf, to increase tobacco taxation (currently at 45.79%) to 70%. Pakistan has a complex three tier tax system, which indirectly boosts cigarette production and consumption, against the spirit of Pakistan’s WHO-FCTC commitments. The WHO has also called on the Pakistan government to immediately abolish the third taxation tier. Currently, Pakistan is facing annual revenue losses of Rs.30 billion (approximately USD193.37 million) due to low taxes on the tobacco industry, while the health of the nation’s youth is at stake.
In addition to increasing taxation, the WHO has called on the Pakistan government to enhance the size of pictorial health warnings to 85% of the cigarette packet The previous Pakistan government announced a plan to gradually enhance the size of the pictorial health warnings but this was weakened after tobacco industry pressure.
In short, the previous government failed to reduce and prevent tobacco use. Tobacco control advocates have pinned great hopes on Pakistan’s current Prime Minister Imran Khan, who came to power in August 2018. Khan has a strong record of working against cancer and was the recipient of WHO’s World No Tobacco Day Award in 2002. In its first budget, Khan’s government imposed a ‘Health Tax’ of Rs.10 (US6c) per pack of 20 cigarette sticks. The size of pictorial health warnings was also increased to 60%. It is anticipated that the Health Tax will generate billions of rupees to be spent on Sehat Insaf Card, a social welfare health insurance scheme. Further, Khan announced an increase in the tobacco tax rate to 70% in upcoming financial budgets. He also ended the tax-free cigarette facility which allowed all Ministers and Governors to purchase tax-free tobacco in the parliament house.
In addition, the Supreme Court of Pakistan also asked the government to launch a public awareness campaign against smoking tobacco, shisha and other hazardous intoxicants. In response, the capital administration of Pakistan announced efforts to make the capital city, Islamabad, a Tobacco–Smoke Free City. The initiative is being undertaken in collaboration with the Capital Administration and Development Division, by creating awareness and enforcement of tobacco control laws. Dr. Nima of WHO Pakistan has stated: “We appreciate this move because it would lead to improvement in healthcare of the people”. He called on Khan’s government to strengthen tobacco control in future, particularly implementation of WHO MPOWER measures with a focus on increased tobacco taxation, large-sized pictorial warning on tobacco packs, and bans on tobacco advertising, promotion and sponsorship”.
Musaddique Hussain is an assistant professor in The University of Faisalabad, Faisalabad, 38,000, Pakistan and Faculty of Pharmacy, The Islamia university of Bahawalpur, Pakistan. Abdul Majeed, Imran Imran, and Muhammad Fawad Rasool are with the Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan. Ikhlaq Hussain is a researcher in Department of Urology, Nishtar Medical University, Multan, Pakistan. Qasim Barkat and Ximei Wu are researchers in the Department of Pharmacology and The Key Respiratory Drug Research Laboratory of China Food and Drug Administration, School of Medicine, Zhejiang University, Hangzhou City, China.
This work is supported to Ximei Wu by National Natural Science Foundation of China (no. 81372046, 81571928, 81470214, 81200022, and 81270067). The authors declare no conflicts of interest.