Policy on Tobacco Control

Proposed by IFMSA-Pakistan QAMC LC and IFMSA-Pakistan CMH LC.

Presented to the IFMSA-Pakistan National General Assembly 2018 in Lahore Medical and Dental College, Lahore.

Policy Commission

  • LC Representative 1 – Harris Ahmed (h.shakeel98@gmail.com)
  • LC Representative 2 – Osama Shahid (osamashahidos@gmail.com)
  • Executive Board Representative – Hina Nasir (vpea.ifmsapakistan@gmail.com)

Policy Statement

Introduction

Pakistan is the 36th largest country by area. The population of the country is approximated to be around 220 million with around 60% living in rural areasƗ and 60 million people living below the international poverty line.

Pakistan is one of the largest tobacco consuming countries in the world. Tobacco is consumed in the form of cigarettes, water pipes (Hookah/Shisha), paan, gutka and naswar. Pakistan is also one of the largest tobacco growing countries in the world. The nicotine and tar content in Pakistani cigarettes is the highest in the world; so, increasing the chances of the users of contracting diseases caused by tobacco use. Prices of tobacco products are also the lowest in the country.

IFMSA Pakistan

  • Notes with deep concern the rapidly rising usage of tobacco among the youth of Pakistan.
  • Is convinced that the usage of tobacco has reached to a point where the intervention by government is essential.
  • Emphasizes urgency in actions.
  • Affirms support to the government and its agencies.
  • Endorses the recommendations of WHO FCTC;
  • And
  • is deeply conscious of its role and strongly affirms that it would render all the support to Government of Pakistan and its agencies and would also voluntarily continue its Anti-tobacco awareness campaigns throughout the country.

Call to Actions

The IFMSA-Pakistan

  1. Calls upon the Government of Pakistan to implement in its true spirit the Prohibition of Smoking and Protection of Non-smoker’s Health Ordinance 2002 and also bring following amendments to the Ordinance for better results:
    • Also include public parks in its definition of ‘‘place of public work or use’’ [Section 2(c)],
    • Increase the distance from 50 meters to 1km in section 9,
    • Increase the amount of fine from 1000 PKR to 100,000 PKR for first time offenders and to set the minimum bar of 1 million PKR for subsequent offenders in Section 11(a).
    • Increase the amount of fine from 5000 PKR to 500,000 PKR for first time offenders and introduce a jail term of not less than one year for anyone who contravenes the provision of Section 8. The bar of subsequent offenders is raised accordingly in Section 11(b).
  2. Also calls for ban on sales of individual cigarette sticks throughout the country;
  3. Recommends adoption of a uniform specific excise tax of 44 PKR per pack of cigarettes;
  4. Urges that cultivation of tobacco be strictly discouraged in the country and steps be taken to restrict the cultivated area to 10,000 hectares;
  5. Further urges that sales of cigarettes be allowed only at licensed shops and sales at other areas be banned completely;
  6. Demands that PEMRA bans all content (dramas, advertisements, talk shows etc.) that project smoking or any other use of tobacco;
  7. Further demands that it may be made compulsory for all channels to show advertisements on hazardous impact of tobacco on health during prime-time transmissions;
  8. Emphasizes that Anti-Tobacco content be made part of the syllabus of high school classes;
  9. Calls for adequate budget allocation for and its utilization on public awareness campaigns, cessation services and research against hazards of tobacco, the campaigns being especially directed towards rural areas of the country;
  10. Adopts the following policy.

Position Paper

Background

Pakistan is the 36th largest country by area. The population of the country is approximated to be around 220 million with around 60% living in rural areas Ɨ and 60 million people living below the international poverty line. 1

Pakistan is one of the largest tobacco consuming countries in the world. Tobacco is consumed in the form of cigarettes, water pipes (Hookah/Shisha), paan, gutka and naswar. Pakistan is also one of the largest tobacco growing countries in the world. The nicotine and tar content in Pakistani cigarettes is the highest in the world; so, increasing the chances of the users of contracting diseases caused by tobacco use. Prices of tobacco products are also the lowest in the country.

Cultivation and Production of Tobacco + Manufacturing of Cigarettes

In Pakistan, during FY 2016-17, tobacco was cultivated on 51000 hectares of land, yielding 113000 tonnes of tobacco. ƗƗ These figures were less than those of the previous financial year. In FY 2015-16, cultivation occurred on 54000 hectares yielding 120000 tonnes of tobacco. In the preceding years; however, the trend was different. The cultivated area had increased from 46000 hectares in 2000-01 to 54000 hectares in 2015-16, while the production increased from 85000 tonnes to 120000 tonnes during the same time period. Ɨ

Production of cigarettes has also been less in the FY 2016-17 than the previous years of this millennium. The manufacturing of cigarettes was at 58,259 Million Nos during FY 2000-01 and was recorded at highest at 75,609 Million Nos during 2008-09. It has decreased since and was at 42,892 Million Nos in 2015-16. In 2016-17, this number has dropped to 24,678 Million Nos. ƗƗ It is; however, noteworthy that one of the reasons sought, apart from decreased demand, was the closure of the factory at Mandra on account of annual maintenance of Pakistan Tobacco Company Ltd. ƗƗ

Tobacco Use in Pakistan

Based on World Health Organization’s 2013 standardized estimate of smoking prevalence, 19.1% of Pakistan’s adult population currently uses tobacco in one form or another. Of these, 9.6 % of the adult population overall are daily cigarette smokers, 2.7 % of the adult population are daily water pipe smokers and 7.1 % of adults use smokeless tobacco daily. Among youth (13-15 y/o), according to the Global Youth Tobacco Survey (GYTS) Factsheet 2013, overall 10.7% were current tobacco users. 7.2% of the youth population overall was smoking tobacco while 5.3 were current smokeless tobacco users. Tragically, the survey noted that 11.2% of the youth who had never used tobacco were susceptible to tobacco use in the future.

Second Hand smoke (SHS) is also a matter of grave concern for the people. As noted in GYTS 2013, 21% of all youth was exposed to tobacco smoke at home while more than 30% was exposed at any public place. GATS 2014 noted that 56% of non-smoking adults were also exposed to SHS in public places.

Economics and Availability

Cigarettes are easily available at stores (90.4%), street vendors (5.0%), kiosks (2.2%) and duty-free shops (1.7%). Smokeless tobacco users purchased the product from stores (73.8%), followed by street vendors (11.0%) and rest from kiosks and duty-free shops. 3 87.6% of youth was able to buy cigarette from all of the above sources as well as from school canteen or pharmacy while 44.9% were not prevented from buying cigarettes because of their age. 35.2% bought cigarettes as individual sticks. 2

Average cost of 20 manufactured cigarettes was Rs. 40.9. On average, current cigarette smoker spent Rs. 767.3 per month on cigarettes and consumed 4500 cigarette sticks annually. 3 In 2014, State Bank of Pakistan reported that Pakistanis had smoked 64.48 billion cigarettes in FY 2014.

Tobacco Taxes in Pakistan 4

Pakistan modified its tobacco excise tax system in 2013. The new system is two tiered. These are:

  • Rs. 880 per 1000 cigarettes with retail price (before VAT) less than or equal to Rs. 2286 per 1000 sticks
  • Rs. 2325 per 1000 cigarettes with retail price (before VAT) greater than Rs. 2286 per 1000 sticks

For a pack of 20 cigarettes, the lower tier amounts to Rs. 17.6 per pack, while the higher tier amounts to Rs. 46.50 per pack.

The 2013 tax structure change is a first step to simplifying Pakistan’s tobacco excises. Adopting a uniform specific excise tax of 31.2 rupees per pack will lead over half a million current Pakistani cigarette smokers to quit smoking and prevent almost 725,000 Pakistani youth from taking up cigarette smoking. These reductions in smoking will prevent over 550,000 premature deaths caused by tobacco use. At the same time, the tax increase will generate over 27 billion rupees (277 million USD) in new cigarette tax revenues.

Health Hazards associated with Tobacco Usage

Tobacco is the single most preventable cause of illness and death worldwide. Its usage kills up to 6 million people a year globally while exposure to SHS causes death of more than 600,000 people each year. Tobacco smoke contains more than 4000 chemicals, out of which 50 can lead to cancer. Lung cancer is largely linked to smoking tobacco. Further, tobacco usage has also been attributed to cancers of bladder, kidney, cervix, breasts, colon and various types of oral and lip cancers. Research also related use of tobacco to increased risk of heart diseases, including heart attack or stroke, as well as major lung diseases which can lead to severe breathing difficulty or failure.

According to a leaflet by Shaukat Khanum Memorial Cancer Hospital and Research Centre, 40% of cancers in adult males seen at the hospital are linked with tobacco while the oral cancer accounts for the second most common cancer seen in the hospital and Pakistan. Risk of oral cancer increases due to usage of smokeless tobacco. GATS 2014 sighted the figures from Pakistan Medical Association that there are 1.5 million cases of oral cancer in the country with many being under the age of 12. Rural areas have high incidence of respiratory diseases that can be attributed to tobacco usage, a point explained later.

Source: Table 1: MPOWER Summary Indicators, GATS 2014

Rural and Urban Disparity

 

Indicator

Overall

Residence

Urban

Rural

Current Tobacco Use

19.1

15.9

21.1

Exposure to second hand smoke at home (atleast monthly)

48.3

36.7

55.7

Exposure to second hand smoke at work

69.1

67.2

71.1

Exposure to second hand smoke at restaurants

86.0

79.7

90.5

Belief that tobacco causes serious illness

85.8

87.8

84.6

Thinking of quitting smoking because of health warnings on cigarette packages

29.7

37.4

26.1

Avg. amount paid for 20 manufactured cigarettes

40.9

45.2

38.6

 

GATS 2014 showed some interesting facts and figures which are worthy of quoting here. According to these, tobacco usage is comparatively more in rural areas than the urban ones and that avg. amount paid for a pack of cigarettes was less in rural areas than the urban. This causes the cigarettes to be more in reach of the people. Also, people in rural areas are more exposed to SHS. These figures are problematic for a very important reason. People who reside in rural areas are mostly poor and have limited financial sources. The increased tobacco usage, exposure to SHS and less avg. price of a pack of cigarettes means that they are more prone to diseases caused by tobacco usage. However, they aren’t able to get themselves medical check-ups and/or medicine and thus, the consequences are worse in the rural areas.

Tobacco Control Measures by Pakistan

In Pakistan, tobacco control can be discussed in three headings:
  1. Legislation;
  2. Perhaps the most important piece of legislation regarding tobacco control is the Prohibition of Smoking and Protection of Non-smokers Health Ordinance, 2002 and Promulgation of Cigarette (Printing of Warning) Ordinance, 1979.

    Few relevant sections of the former ordinance are being quoted here for reference:

    • Prohibition of smoking and other tobacco use. - No person shall smoke or use tobacco in any place of public work or use. The Federal Government may however issue guidelines for the permitting designed smoking areas in premises or places where adequate arrangements are made to protect the health of non-smokers.
    • Prohibition of smoking in public service vehicles. - Without prejudice to the provisions of the Provincial Motor Vehicle Ordinance, 1965 (W.P. Ordinance XIX of 1965), no person shall smoke or use tobacco in any other form in any public service vehicle.
    • Prohibition of sale of cigarettes etc. to minors. - No person shall sell cigarettes, or any other such smoking substance to any who is below the age of eighteen years.
    • Prohibition of storage, sale and distribution of cigarettes, etc. in the immediate vicinity of educational institutions. - No person shall himself or by any person on his behalf, store, sell or distribute cigarettes or any other such smoking substance within an area of 50 meters from any college, school or educational institution.
    • Penalties. - Any person, who contravenes the provisions of:-
      • section 5, 6 or 10 shall be punishable with fine which may extend to one thousand rupees and in case of second or subsequent offence, shall be punishable with a fine which shall not be less than one hundred thousand rupees; and
      • section 7, 8 or 9 shall be punishable with fine Which may extend to five thousand rupees and in case of second or subsequent offence, shall be punishable with imprisonment which may extend to three months, or with a fine which shall not be less then one hundred thousand, or with both.
  3. Pakistan became a signatory of WHO Framework Convention on Tobacco Control (FCTC) in 2005.
  4. Creation of Tobacco Control Cell at Federal Level; Working under the Ministry of National Health Services, Regulation and Coordination, the cell is to implement the FCTC articles in the country. It does so by coordinating with relevant offices to raise awareness about hazards of tobacco use, implementation of Anti-tobacco laws and to reduce the demand and supply of tobacco products.

References

  • Ɨ. Pakistan Economic Survey 2015-16
  • ƗƗ. Pakistan Economic Survey 2016-17
  • 1. /https://www.dawn.com/news/1250694
  • 2. GYTS Factsheet Pakistan 2013
  • 3. GATS 2014
  • 4. http://global.tobaccofreekids.org/files/pdfs/en/Pakistan_tobacco_taxes_summary.pdf

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