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REVIEW ARTICLE
Year : 2011  |  Volume : 55  |  Issue : 3  |  Page : 161-168  

Social, economic and legal dimensions of tobacco and its control in South-East Asia region


Tobacco Free Initiative, World Health Organization, Regional Office for South-East Asia

Date of Web Publication16-Nov-2011

Correspondence Address:
Nyo Nyo Kyaing
Regional Advisor (Tobacco Free Initiative), World Health Organization, Regional Office for South-East Asia, IP Estate, New Delhi, India

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-557X.89944

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   Abstract 

This paper examines the social, cultural, economic and legal dimensions of tobacco control in the South-East Asia Region in a holistic view through the review of findings from various studies on prevalence, tobacco economics, poverty alleviation, women and tobacco and tobacco control laws and regulations. Methods were Literature review of peer reviewed publications, country reports, WHO publications, and reports of national and international meetings on tobacco and findings from national level surveys and studies. Tobacco use has been a social and cultural part of the people of South-East Asia Region. Survey findings show that 30% to 60% of men and 1.8% to 15.6% of women in the Region use one or the other forms of tobacco products. The complex nature of tobacco use with both smoking and smokeless forms is a major challenge for implementing tobacco control measures. Prevalence of tobacco use is high among the poor and the illiterate. It is higher among males than females but studies show a rising trend among girls and women due to intensive marketing of tobacco products by the tobacco industry. Tobacco users spend a huge percent of their income on tobacco which deprives them and their families of proper nutrition, good education and health care. Some studies of the Region show that cost of treatment of diseases attributable to tobacco use was more than double the revenue that governments received from tobacco taxation. Another challenge the Region faces is the application of uniform tax to all forms of tobacco, which will reduce not only the availability of tobacco products in the market but also control people switching over to cheaper tobacco products. Ten out of eleven countries are Parties to the WHO Framework Convention on Tobacco Control and nine countries have tobacco control legislation. Enforcement of control measures is weak, particularly in areas such as smoke-free environments, advertisement at the point of sale and sale of tobacco to minors. Socio-cultural acceptance of tobacco use is still a major challenge in tobacco control efforts for the governments and stakeholders in the South-East Asia Region. The myth that chewing tobacco is less harmful than smoking tobacco needs to be addressed with public awareness campaigns. Advocacy on the integration of tobacco control with poverty alleviation campaigns and development programs is urgently required. Law enforcement is a critical area to be strengthened and supported by WHO and the civil society organizations working in the area of tobacco control.

Keywords: Social, Culture, Tobacco use, WHO FCTC


How to cite this article:
Kyaing NN, Islam MA, Sinha DN, Rinchen S. Social, economic and legal dimensions of tobacco and its control in South-East Asia region. Indian J Public Health 2011;55:161-8

How to cite this URL:
Kyaing NN, Islam MA, Sinha DN, Rinchen S. Social, economic and legal dimensions of tobacco and its control in South-East Asia region. Indian J Public Health [serial online] 2011 [cited 2019 Jun 26];55:161-8. Available from: http://www.ijph.in/text.asp?2011/55/3/161/89944


   Introduction Top


The WHO South-East Asia Region consists of eleven countries, viz. Bangladesh, Bhutan, DPRK, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste. The South-East Asia is amongst the biggest producers and consumers of tobacco products in the world.

Survey findings show that 30% to 60% of men and 1.8% to 15.6% of women in the South-East Asia Region use some form of tobacco. [1] Other than cigarettes, smoked products such as cigars, pipes, bidis, hand-rolled cigarettes, kreteks, hookahs or cheroots are common in the Region. Use of smokeless tobacco products for chewing in many varieties is highly prevalent in Bangladesh, India, Myanmar and Nepal and people think that chewing is not as hazardous to health as smoked products. A gradual shift is being noticed from more traditional and hand-made tobacco products towards industrially manufactured tobacco products, even for smokeless products like guttka, gul, zarda, etc. Although smoking is still predominantly a male habit, use of smokeless tobacco, particularly chewing, is common among both men and women. Recent surveys clearly indicate that tobacco use among young girls and women in the Region is on the rise. [2]

As tobacco is an economic product, its production and consumption have an impact on economic lives of a society. Even though tobacco is a high yielding cash crop, agriculturists do not understand the long term harms it causes to the land and human health. Since tobacco is also a vital source of revenue for the governments in many of the South-East Asia countries, governments are not so keen to look for an alternative cropping systems and also given the fact that tobacco industry plays a crucial role in maintaining status quo for tobacco cultivation. Economic impacts of tobacco use on productivity and health care are disproportionately felt by the poor since they are much more likely than the rich to become ill and die prematurely from tobacco related illnesses. There is enough scientific evidence that tobacco use is depriving poor households of nutrition, education and health. The immediate impact of hospitalization cost due to tobacco-related morbidity and mortality is not only money per se but also loosing earning members in a family that could potentially push the whole family into poverty. This creates greater economic hardships and perpetuates the cycle of poverty and illness. The problem of tobacco is also compounded by the inadequate financial support that the tobacco control programmes receive from the governments. The recent report reveals that governments collect nearly US $ 133 billion in tobacco excise tax each year, but expenses made towards tobacco control is less than 1% of the total tax revenues. [3]

The WHO Framework Convention on Tobacco Control, the first public health treaty which was adopted in 2003 and came into force in 2005, has provisions for Parties to have comprehensive legislation to curb the tobacco epidemic. Ten Member countries from SEA Region are Parties to the Convention and nine countries have adopted tobacco control legislations.

This paper looks into the socio-economic and legal dimensions of tobacco control in the South-East Asia Region.


   Results of situation analysis Top


Socio-cultural dimension

Tobacco is an integral part of the culture and tradition in many countries of the South-East Asia Region. Tobacco serves various purposes in communities and gives different meanings to societal mores and relations. In Myanmar, tobacco use has been culturally and socially accepted and has become an element of social norms. Tobacco products are given to guests during social gatherings and religious ceremonies. [4] Offering raw tobacco by children to the elderly as a present during their visit is a common practice in some communities in Kerala, India and tobacco is also used in celebrations including marriage. [5] Tobacco water called taibur is offered to guests or visitors as a form of greeting and is an essential item at parties in rural areas in Mizoram, India. [6] Sharing a hookah among the rural north Indian men is seen as a symbol of companionship, solidarity and consultative process. [7] In Nepal, tobacco chewing is more socially acceptable than smoking among women in rural areas while smoking is considered as a symbol of independence among urban women and young people. [8] On the other hand, there are also some beliefs and practices about tobacco that hinder its use in few countries. For instance, people in Myanmar believe that tobacco smoke harms the foetus and husbands keep away from smoking and instead choose to use smokeless tobacco when their wives are pregnant. Sikhism in India does not allow tobacco use because it was banned by a Sikh Guru in the 17 th century and even today the prevalence of tobacco use is low in Punjab where the main religion is Sikhism. [7] Likewise, Bhutanese people generally consider using tobacco as a sin and tobacco consumption in the country is very low. The community-led initiatives called for a ban on both production and sales of tobacco in Bhutan. [1] In Sri Lanka, smoking among women is regarded as a "village behavior" and not appreciated by urban women. [9] Therefore, tobacco use is intimately woven into the social and cultural fabrics of the people of the countries of South-East Asia.

Tobacco use and its pattern are closely linked to age, sex, social class, education, income, etc amongst many other factors. Findings from studies in the Member countries of the Region reveal that tobacco use is higher among the rural, illiterate and poor population. The use of tobacco among rural people in Bangladesh, India and Thailand was higher than the urban population [Figure 1]. In Nepal, educated women were four times less likely to smoke than those who were illiterate. [10] People of lower economic classes in India tend to smoke bidis more and have a higher level of social acceptance than those in upper classes. [11] Literacy is found to greatly affect the rates of smoking among population. Findings of Global Adult Tobacco Survey (GATS) show that there is a significant difference in tobacco use among people by the level of education. For example, the tobacco use among people without formal education is three-fold higher than among those who have been schooled up to secondary and above in Bangladesh. The use of tobacco among illiterate people in India is twice as high as those who completed secondary education while Thailand also represents the same trend [Figure 2]. It is found that tobacco use is inversely related to income and wealth. People in the lower income brackets tend to use more tobacco than those in the higher income bracket. For instance, tobacco use is two times higher among the lowest income group than those in highest income group in Bangladesh. [12]

Smoking among adult women is much lower than men in the Region as it is socially not acceptable for women and tobacco use is restricted. GATS reports reveal a huge variation in tobacco use between men and women. Tobacco use among women varies from 9.1% (Thailand) to 28% in Bangladesh [Figure 3]. However, recent trends show that the rates of current smoking among girls in the 13-15 age group of students is increasing. The findings of the GATS also point towards an increasing prevalence of tobacco use among women in Bangladesh and India.
Figure 1: Percentage of current tobacco users in selected Member countries of South-East Asia, by residence

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Figure 2: Percentage of current tobacco users in selected Member countries of South-East Asia, by education level

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Figure 3: Percentage of current tobacco users in selected Member countries of South-East Asia, by gender

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Smoking among youth is also not a cultural norm in most countries in the Region since it is regarded as an "adult behaviour". Many factors seem to influence the use of tobacco among youth such as tobacco use by elders, peer pressure, experimentation, attitudes, curiosity, etc. Those students in Kerala who have fathers using tobacco at homes were two times more likely to use tobacco compared with their peers who did not have any tobacco users at home. [5] One study in India reveals also that many adolescents pick up the habit of tobacco use from their family members or their the peers. [13] However, a change in the cultural trends was noted as shown by Global Youth Tobacco Survey reports (GYTS) that as many as 24% to 48% of students aged 13-15 years were current smokers and many were smoking at homes. One study in India also found that students exposed to tobacco advertisement during sports events and other televised programs, newspapers or magazines were significantly more likely to be smokers. [14]

On the other hand, there is a gross misconception among people about tobacco use. About 40% of tobacco users in Thailand believe that a hand-rolled cigarette is less harmful than manufactured cigarettes and this belief is common particularly among the rural population where its use is also high. [15] Due to a widespread misconception about tobacco being good for the teeth and oral health, people in many parts of India use tobacco products as dentifrices in different forms such as tobacco toothpaste, tooth powder, roasted and powdered tobacco, dry snuff, etc. [6] In North eastern states of India, people believe that tobacco water, which is called tuibur, protects against the bites of insects and it acts as an antiseptic, protects the teeth and has anti-snake venom properties. [16] Truck drivers, rickshaw drivers and manual labourers in Myanmar believe that tobacco keep them alert and make them more productive at work. [17] Youth also have the perception that smoking makes them look more attractive. The GYTS reports show that more than 20% of youth in Bangladesh, Myanmar, Nepal, Sri Lanka and Timor-Leste think that boys and girls who smoke look more attractive.

Tobacco use in the Region is intricately associated with the socio-cultural factors prevailing in the communities. Tobacco is socially acceptable and being promoted openly in some communities while it is equally proscribed in others. The extent and pattern of use is also influenced by socio-demographic indicators such as gender, income, education level, wealth, etc. In some communities, misconception about tobacco is triggering its use among the masses including youth.

Economic dimension

Economic studies have shown that people are losing a significant part of their income to purchasing tobacco products. Studies reveal that poor smokers spend up to 40% of their income on tobacco at the cost of their basic needs that in turn push them further deeper into a cycle of poverty. [12] In Myanmar, tobacco users who are in the lowest income group spend as high as 33% of their income on tobacco. [17] In general, cost incurred on tobacco consumption comprises about 14% of the family expenditure. [4] The poorest households in Bangladesh spend almost 10 times as much on tobacco as on education, while the money spent on tobacco by the lowest income group is about 15% of total family expenditure. [12] It is estimated that tobacco consumption pushes approximately 15 million people into poverty in India. [18]

Studies conducted on Tobacco Economics in Member countries including Bangladesh, Myanmar, Nepal and Thailand by WHO and the World Bank show that health and economic consequences of tobacco use is much more than the revenues received from tobacco. For instance, the cost of treatment of diseases attributable to tobacco use was more than double the revenue that governments received from tobacco in Bangladesh. [19]

Tobacco use induced morbidity and mortality cause considerable economic loss both directly and indirectly. The direct cost is related to the loss of labour productivity and quality of life of people while health care cost is huge to treat diseases often contributing to impoverishment. For example, three tobacco related diseases-heart disease, stroke and cancer caused the Indian government US $ 5.8 billion in health care expenditure, in contrast to the revenue of US$ 1.5 billion that the Government collected from the tobacco industry in 2000. [20] Apart from the economic cost, the sufferings, physical and emotional distress and the loss due to death of smokers to the families and societies are enormous. Amount gained as revenue from tobacco exceeds the cost incurred to society due to tobacco use.

Taxation and tobacco control

The Member countries of South-East Asia have been striving to increase the tax rates on tobacco products and strengthen the tax administration for tobacco control. Bangladesh is imposing duty and VAT on the un-manufactured tobacco products and smokeless products. India is going to introduce the Goods and Services Tax (GST) with cascading tax rates. Indonesia has simplified its tobacco tax regime while Thailand has kept increasing tax rates progressively in keeping with the rate of inflation. Although many countries have increased taxes in every fiscal year, over the last decade, cigarettes have become more affordable as inflation and the growth in per capita income have not been taken into account while raising the tax. Also, according to the Global Progress Report 2010 on the FCTC implementation, the average total tax rate levied on cigarettes was 57.7% in the Region which is less than the World Bank's recommended threshold of 67%. [1]

Generally there is a tendency to tax cigarettes more than other non-cigarette tobacco products like bidi or chewing tobacco. Due to a relatively higher cost for cigarettes, consumers often switch over to low-taxed and cheaper tobacco products. Since mostly the poorer sections of the society use cheaper products, they are the ones affected by taxation. The argument behind the low tax on non-cigarettes tobacco products is based on the pro-poor principle. But the studies have shown that the burden of tobacco related diseases is borne most heavily by low income households. Hence, the real pro-poor objective is to make tobacco unaffordable to the poor.

The scheme of introducing dedicated taxation for health promotion, including using these funds for prevention and control of the use of tobacco as well as alcohol, is getting increasingly popular. Thailand and India are two good examples in the Region where a part of tobacco taxation is earmarked for health issues. India introduced taxation on tobacco for use in welfare promotion of bidi workers and for generating resources for a national calamity fund for some years. It has recently made arrangements for a certain proportion of tobacco taxation to supplement the funding for National Rural Health Missions. [1] Thailand has taken advanced steps towards innovative financing for health promotion by using dedicated 2% of the tax on cigarettes and alcohol for heath promotion activities as mandated by Thai Health Foundation Act. [21]

Legal dimension

The collective civil society movements demanding for stronger tobacco control laws, emerging scientific knowledge on the harmful effects of tobacco, and some stronger actions for tobacco control influenced the legal development process in the countries. The recommendations of World Health Organization, specially the WHA resolutions of 1986 and 1990, were instrumental in adopting a national comprehensive tobacco control law in the countries. Regulations for controlling smoking at designated places, specified health warnings on cigarette packs and restricting tobacco trade had been in existence decades before the modern tobacco control era came into being. However, it is the WHO Framework Convention on Tobacco Control (WHO FCTC) and its guidelines that provided the foundation for countries to formulate comprehensive tobacco control legislation.

In South-East Asia, so far, nine of the eleven member countries have formulated comprehensive tobacco control legislation incorporating provisions of the Framework convention. Even though Indonesia and Timor-Leste are still without a comprehensive law, Governments are already implementing certain regulations and measures on tobacco control. All countries have included tobacco control in their health programmes and have focal points in the Ministries of Health to coordinate and implement tobacco control activities. Task forces have been constituted at the national and sub-national levels to facilitate the implementation of tobacco control programmes efficiently and synergize the collaborative efforts of various stakeholders such as non-governmental organizations, development partners, research institutes, community members, etc.

Countries are in different stages of implementing tobacco control national laws and regulations. However, they are not in full compliance with the provisions of the WHO Framework Convention. There is a need to strengthen and amend the laws from lessons learnt in countries and other parts of the world. Thailand is a good example with a long history of tobacco control movements where the laws have been evolving in keeping with the changing needs and developments in tobacco control situations. Several success stories are credited to this country with banning a display of tobacco promotion at the point of sale, making most of public places smoke-free and depicting graphic health warnings on tobacco product packages. In the similar line, India also formulated and updated a number of regulations and notifications and the latest one is on the introduction of new series of pictorial health warnings that would be effective from December 2011. [22]

Different surveys show that two in five adolescents and nearly one-third of adults are exposed to second-hand smoke (SHS) in public and work places in the Member States of the Region. Although legislation in many countries have included provisions for making smoke-free places [Table 1], the enforcement of the provisions remains a big challenge. However, there are also successful stories of implementing smoke-free measures in countries likes Bhutan, DPR Korea, Maldives and Thailand where all public places including restaurants and bars are declared smoke-free. Other countries are at various stages of strengthening their policies and regulations on smoke-free environment.
Table 1: Implementation of smoke-free policies in the Region

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While almost all countries have legal provisions for specific health warnings on the tobacco packs, only four countries (Bangladesh, India, Thailand and Indonesia) have been able to put those into practice. Bangladesh implements six rotating textual-specific health warnings on manufactured cigarette packs. India has introduced graphic health warnings on all kinds of manufactured tobacco products and recently upgraded a new series of graphic warnings. In Indonesia, a health warning is used on the cigarette packs although it does not follow the stipulations of the Convention. Depiction of health warnings in Thailand is comparable to the best in the world since ten rotating graphic warnings covering 55% of the front and back of cigarette packets, five rotating graphic warnings on cigars covering 50% and two graphic warnings on Roll Your Own cigarettes are being implemented. The recently adopted tobacco control legislation of Nepal has provisions for pictorial health warnings covering at least seventy-five per cent of packet/wrappers in Nepali language. [23]

While almost all Member countries have totally banned direct advertisement of tobacco on national TV and radio, the majority have no control on international TV and radio advertisements. The GYTS data reveal that over 60% of students are exposed to advertisements on billboards and newspapers in many countries. The GYTS results also show that one in ten students have seen objects with brand logos of cigarettes and one in ten students have been offered free samples of cigarettes in most Member countries in the Region, which are banned in the tobacco control laws. A number of countries in the Region have included provisions to ban sale of tobacco products to and by minors. However, the enforcement remains here as a huge challenge. The percentage of boys and girls who could get cigarettes in a store ranges from a high of 75% in Sri Lanka to 24% in Myanmar. Almost every current smoker among youth in Bangladesh (98%) can get cigarettes without refusal from sellers because of their age.


   The way forward Top


Tobacco use is deeply embedded in the culture of the South-East Asia. The tobacco industry uses these social and cultural beliefs of people to its advantage and markets their products intensively. Smoking by young women was not a social norm as smoking is seen as an adult male behaviour, but the scenario is changing as there is a rising trend of smoking among girls and women. Community-based programmes led by community leaders: Religious persons, teachers, youth and civil society have proved to be successful. These should be enhanced and strengthened. Media advocacy is also crucial in this area.

The myth of smokeless tobacco as less harmful than smoked products is a major challenge in the Region. India has the highest rates of oral cancer in the world due to the very high prevalence of chewing tobacco in various forms. This misbelief has to be addressed intensely and widely among the community. Legislation should cover smokeless tobacco and uniform taxation must be imposed on both non-cigarette smoked and smokeless tobacco products. the Bidi industry has tried to protect themselves as 'poor cottage industries' and as a source of employment for the poor. Bangladesh government has recently proposed a new budget to the parliament in June 2011 which increased taxes on cigarettes but excluded bidis. Loss of revenue and jobs are the main arguments of the tobacco industry. However, studies have found that far fewer employees actually earned a livelihood from tobacco factory alone. They depended on different sources of incomes. On the contrary, women and children, who make up a large portion of tobacco workers, are exploited as cheap source of labour for tobacco industry. Governments and tobacco control programmes should counter such arguments with concrete evidence generated through research proving that tobacco brings much harm to the society than any good, and disseminate scientific information to and educate general public on the detrimental effects of tobacco through awareness campaigns, advocacy workshops, multi-stakeholder meetings and mass media.

Another economic measure for controlling tobacco through supply reduction is to promote economically viable alternatives for tobacco workers, growers and in cases may be individual sellers. Article 17 of WHO FCTC has included this provision as a major supply reduction measure. Countries like India, Bangladesh, and Thailand have initiated some policy discussions, research and some measures to discourage tobacco farming and processing. But this is a major area that needs to develop further for effective control of supply and use of tobacco.

Tobacco control as an important part of poverty alleviation should be widely advocated to policy makers. Studies on Tobacco Economics should be repeated in all Member States. The studies on poverty alleviation as well as health impact studies have been found to be very useful policy advocating tools; this kind of research should be conducted with the support of WHO and World Bank in all Member States. Integration of tobacco control programme with development programmes, poverty alleviation programmes, health promotion programmes and NCD control programmes will lead to a significant decline in tobacco use.

Law enforcement is vital for effective implementation of the WHO FCTC. Countries have adopted legislation but enforcement is still weak. WHO and all stakeholders should prioritize training of law enforcers and public education for compliance for the legislation. WHO could also provide technical support for development of rules, regulations, notifications and amendments. More importantly, countries need to increase resources (financial and human) for tobacco control programmes not only for meeting the legal obligations of the WHO FCTC but also to successfully contain the risk of non-communicable diseases (NCDs) as tobacco is the biggest risk factor for NCDs.

Tobacco is a formidable public health problem due to its major effects on morbidity and mortality. However, it is different from other public health issues for it has strong socio-cultural and economic linkages and is being promoted by strong economic actors. Governments and health policy makers in the Region are striving for controlling the menace through legal and public health measures. The counties are also captivating global cooperation in tobacco control through adoption and implementation of WHO FCTC and other international initiatives in the area of research, surveillance and financing in tobacco control. However, since the socio-cultural and economic elements are critical in the tobacco issue, the tobacco control programmes need a comprehensive strategy which should combine measures for socio cultural change and actions for demand and supply reduction. The legal and economic measures for demand reduction should also be supplemented with education and awareness raising programmes.

Advocacy to the policy makers for strengthening policies and practical approach to enforcement must be given a high priority. At the same time, capacity of law enforcers on the tobacco control laws must be enhanced and public education campaigns on compliance of the law intensified. The support of Bloomberg Philanthropies should be continued in the South-East Asia Region to help implement the MPOWER measures in countries and achieve the goals of the WHO Framework Convention.

 
   References Top

1.World Health Organization, Regional Office for South-East Asia. Profile on Implementation of WHO Framework Convention on Tobacco Control in South-East Asia Region. New Delhi, India, 2011.   Back to cited text no. 1
    
2.World Health Organization, Regional Office for South-East Asia (SEARO), 2010. Brief Profile on Gender and Tobacco in South-East Asia Region. New Delhi, India, 2010.   Back to cited text no. 2
    
3.World Health Organization. WHO Report on Global Tobacco Epidemic, 2011: Warning about the dangers of tobacco. Geneva, 2011.   Back to cited text no. 3
    
4.World Bank and World Health Organization. Tobacco Economics in Myanmar. HNP Discussion Paper, Economics of Tobacco Control Paper No. 14. 2003.   Back to cited text no. 4
    
5.Thankappan KR, Thresia CU. Tobacco use and social status in Kerala. Indian J Med Res 2007;126:300-8.  Back to cited text no. 5
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6.Sinha DN, Gupta PC, Pednekar M. Tobacco Water: A special form of tobacco use in Mizoram and Manipur states In India. Natl Med J India 2004;17:245-7.  Back to cited text no. 6
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7.Government of India, Ministry of Health and Family Welfare. Report on Tobacco Control in India. New Delhi, India, 2004.   Back to cited text no. 7
    
8.Government of Nepal, Ministry of Health and Population. Brief Profile Tobacco Control in Nepal. Katmandu, Nepal, 2010.   Back to cited text no. 8
    
9.World Health Organization, Regional Office for South-East Asia. Regional situation analysis of women and tobacco in South-East Asia. New Delhi, India, 2004.   Back to cited text no. 9
    
10.World Bank and World Health Organization (WHO). A Study on the Economics of Tobacco in Nepal. HNP Discussion Paper, Economics of Tobacco Control Paper No.13, 2003.   Back to cited text no. 10
    
11.Gupta PC, Asma S, editors. Bidi Smoking and Public Health, New Delhi: Ministry of Health and Family Welfare, Government of India, 2008.   Back to cited text no. 11
    
12.Efroymsona D, Ahmed S, Townsend J, Mahbubul Alam SM, Dey AR, Saha R, et al. Hungry for tobacco: An analysis of the economic impact of tobacco consumption on the poor in Bangladesh. Tobacco Control 2001;10:212-7.   Back to cited text no. 12
    
13.Singh G, Sinha DN, Sharma PS, Thankappan KR. Prevalence and Correlates of Tobacco Use among 10-12 year old students in Patna District, Bihar, India. Indian Pediatr 2005;42:805-9.   Back to cited text no. 13
    
14.Shah PB, Pednekar MS, Gupta PC, Sinha DN. The relationship between tobacco advertisements and smoking status of youth in India. Asian Pac J Cancer Prev 2008;9:637-42.  Back to cited text no. 14
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15.WHO. Regional office for South East Asia. Global Adult Tobacco Survey: Thailand Country Report 2009. New Delhi, India, 2009. (Available from: http://www.who.int/tobacco/surveillance/thailand_gats_report_2009.pdf). [Last accessed on 2011 July 18].  Back to cited text no. 15
    
16.Sinha DN, Gupta PC, Pednekar M. Use of tobacco products as dentifrice among adolescents in India: Questionnaire study. BMJ 2004;328:323-4.  Back to cited text no. 16
    
17.World Bank and World Health Organization. Study on Poverty Alleviation and Tobacco Control in Myanmar. HNP Discussion Paper, Economics of Tobacco Control Paper No. 31, 2005.  Back to cited text no. 17
    
18.John RJ, Sung HY, Max WB, Ross H. Counting 15 million more poor in India, thanks to tobacco. International Tobacco Control, American Cancer Society, Atlanta, Georgia, USA. (Available from: http://www.ncbi.nlm.nih.gov/pubmed/21292807). [Last accessed on 2011 July 5].  Back to cited text no. 18
    
19.WHO. Regional Office for South-East Asia. Impact of Tobacco Related Illness in Bangladesh. New Delhi, India, 2007.   Back to cited text no. 19
    
20.Madur G. India Finalizes Tobacco Control Legislation. BMJ 2001;322:386.   Back to cited text no. 20
    
21.Thai Health Promotion Foundation. Health Promotion Foundation Act, B.E. 2544 (2001).  Back to cited text no. 21
    
22.Government of India. Ministry of Health and Family Welfare (Department of Health and Family Welfare), Notification on amendment to the COTPA rules, 2008. Gazette of India, Extraordinary, May 27 th , Pt. II, Sec. 3, sub-section (i), 2011.   Back to cited text no. 22
    
23.Government of Nepal. Ministry of Health and Population. National Health Education, Information & Communication Centre. Tobacco Product (Control and Regulatory) Bill, 2010.  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]


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