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| REVIEW ARTICLE |
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| Year : 2011 | Volume
: 55
| Issue : 3 | Page : 199-209 |
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Smokeless tobacco: A major public health problem in the SEA region: A review
Prakash C Gupta1, Cecily S Ray1, Dhirendra N Sinha2, Poonam K Singh2
1 Healis - Sekhsaria Institute for Public Health, Navi Mumbai, India
2 World Health Organization, Regional Office for South-East Asia, New Delhi, India
| Date of Web Publication | 16-Nov-2011 |
Correspondence Address:
Cecily S Ray
Senior Research Fellow, Healis-Sekhsaria Institute for Public Health, 601/B Great Eastern Chambers, Plot no. 28, Sector 11, CBD Belapur, Navi Mumbai - 400 614
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0019-557X.89948
 Abstract | | |
Smokeless tobacco use is on the upswing in some parts of the world, including parts of SEAR. It is therefore important to monitor this problem and understand the possible consequences on public health. Material for this review was obtained from documents and data of the World Health Organization, co-authors, colleagues, and searches on key words in PubMed and on Google. Smokeless tobacco use in SEAR, as betel quid with tobacco, declined with increased marketing of cigarettes from the early twentieth century. Smokeless tobacco use began to increase in the 1970s in South Asia, with the marketing of new products made from areca nut and tobacco and convenient packaging. As a consequence, oral precancerous conditions and cancer incidence in young adults have increased significantly. Thailand's successful policies in reducing betel quid use through school health education from the 1920s and in preventing imports of smokeless tobacco products from 1992 are worth emulating by many SEAR countries. India, the largest manufacturing country of smokeless tobacco in the Region, is considering ways to regulate its production. Best practices require the simultaneous control of smokeless and smoking forms of tobacco. Governments in SEAR would do well to adopt strong measures now to control this problem. Keywords: Epidemiology, Health policy, Neoplasms, Prevalence, Smokeless, Tobacco, Tobacco industry, Trends
How to cite this article:
Gupta PC, Ray CS, Sinha DN, Singh PK. Smokeless tobacco: A major public health problem in the SEA region: A review. Indian J Public Health 2011;55:199-209 |
How to cite this URL:
Gupta PC, Ray CS, Sinha DN, Singh PK. Smokeless tobacco: A major public health problem in the SEA region: A review. Indian J Public Health [serial online] 2011 [cited 2023 Mar 23];55:199-209. Available from: https://www.ijph.in/text.asp?2011/55/3/199/89948 |
| Introduction | |  |
Smokeless tobacco use is on the upswing in parts of the world, including some countries of the South East Asian Region (SEAR) of the World Health Organization. Governments need to take strong measures now to prevent it from spreading further within and beyond the region. The recommendation of not allowing smokeless tobacco products to be imported in countries where their use was not already established was made by the World Health Organization as far back as 1988. [1]
In South and South-East Asia, the chewing of betel quid with tobacco began sometime after tobacco was introduced into the region around 1600 and it became highly prevalent by the second half of the eighteenth century. [2] The prevalence of betel quid chewing slowly decreased in the twentieth century mainly because cigarette smoking began to replace it, as it was considered more modern. Nowhere in the South-East Asia Region was this change more evident than in Thailand.
From the second half of the 1960s onwards, smokeless tobacco use increased progressively in the United States and Sweden among young males until the late1980s due to the emergence of new aggressively marketed products. [3] This led over the next two decades to sustained growth and greatly increased sales and prevalence rates of smokeless tobacco use, especially in teenage and young adult males. [4]
In South-East Asia also, beginning with India, a resurgence in smokeless tobacco got started in the 1970s and then took off in a greater way in 1985 when it began to be sold in single portion pouches. Growth of these products is still on the upswing. The initial products, generically called pan masala, made from finely chopped areca nut, catechu, lime, spice flavorings, saccharine and other additives, were sold in two versions: one with tobacco and the other without. Depending on the manufacturer, the products with tobacco are called pan masala with tobacco or gutka. Well-targeted advertisements on television made the products trendy nation-wide. Cheaper, vendor made products with similar ingredients were also popularized (e.g., mawa, Mainpuri tobacco, and dohra). [5]
This was especially true in Gujarat, where mawa, pan masala and gutka became simultaneously popular. By the end of the 1980s a marked increase in the occurrence of oral submucous fibrosis had been reported in Gujarat, especially among males < 35 years. [6] By the end of the 1990s, an incipient epidemic of oral cancer in individuals < 50 years was detected in the in Ahmedabad Cancer Registry. This was evidence for the strong carcinogenicity of the dry areca nut and tobacco products consumed without the betel leaf. [7]
The packaged areca nut and tobacco products soon began to be exported to neighboring countries in SEAR and the Eastern Mediterranean Region (EMR) and parts of the world where South Asians had emigrated. In the new millennium, other traditional smokeless tobacco products, such as khaini, chewing tobacco and zarda, also began to be marketed in similar ways and exported, which seems to have resulted in their increased popularity.
Although smoking predominates over smokeless tobacco in most countries of SEAR countries today, [8] smokeless tobacco use is increasing in parts of the Region.
In the current scenario of increasing smokeless tobacco use in the region, it may be useful to look at some examples of good practices. This paper describes the extent of the problem and also attempts to point the way forward.
Material for this review was obtained from documents and data of the World Health Organization, co-authors, colleagues, and searches on key words in PubMed and on Google.
| Examples of smokeless tobacco control | | |
In reducing betel quid use, the case study of Thailand is interesting and illustrative. In the 1920s, betel quid chewing with tobacco was very common in Thailand and oral cancer was deemed a major public health problem. Nearly half of all cancer cases seen in hospitals were in the oral cavity. Due to the concern of public health officials, schools began to teach against betel quid chewing. This resulted in a marked decline in betel quid chewing by 1955, and a decrease in numbers of cases from 1988. [9] From 1988-91 to 1999, the age standardized incidence rates for oral cancer in Thailand dropped from 3.6 to 1.2 in males and 2.6 to 1.1% in females. Similar trends were seen in both sexes for cancer of the tongue, oropharynx and hypopharynx. [10] Betel quid vendors still sell their wares in the stalls of markets in Thailand, but vendors say the regular customers are rare, mostly elderly women. Other betel quid purchases are mainly for ceremonial purposes. Young people say they avoid using betel quid because they are afraid of their teeth turning black. Vendors are largely unaware of side effects of betel quid and consider the practice good for the teeth. The vendors are also conscious of betel quid use dying out along with the smoking of traditional cigars (khi yo). Both are being replaced by cigarette smoking and alcohol drinking. [11] According to the GATS survey of 2009 in Thailand, only 0.9% of men and 5.8% of women are daily smokeless tobacco users (betel quid with tobacco). [12] It is a different matter that the health gains obtained by reducing betel quid use were more than offset by an increase in smoking during the same period.
Another example of the successful preventive action for control of smokeless tobacco, again in Thailand, is the banning of the import of foreign smokeless tobacco products into the country. In 1992, a well-known tobacco control activist of Thailand, Dr. Hatai Chitanond, noticed some boxes of a brand of smokeless tobacco, bearing the excise stamp, displayed at a pharmacy. The shop attendant informed him that these products were bought by foreign tourists. At this time, Dr. Chitanond was still in the post of Secretary of the National Committee for the Control of Tobacco Use (NCCTU), under the Ministry of Health. He was naturally very concerned about these deadly products, to which so many American youths had fallen prey, being sold in his own country, where no one would be aware of the danger they posed. Realizing the products had been sold legally, as they bore the excise stamps, he contacted the Excise Department for clarification and learned that an import permit had been granted for that brand of smokeless tobacco after some foreign tourists had asked to buy it in shops. [13] He and his office then approached the Ministry of Finance and asked for a ban on smokeless tobacco imports as they posed a danger to the people of Thailand. The Finance Minister then agreed to ban the import of smokeless tobacco products. Although the US Embassy tried to intervene, it could not stop the ban because it was legal under GATT (General Agreement on Tariffs and Trade), as it applied equally to domestic Thai production. Since nowhere in Thailand such products were being manufactured, there was no compulsion under international law to permit their import, [14] the ban was successfully implemented. [11] Two decades later, however, Internet blogs of foreign visitors to Thailand record them asking each other where they can find smokeless tobacco in the country. Some say they have found it, which indicates there is some level of illegal import of the products. Thus an additional lesson is that a mechanism for constant vigilance for illegal imports of smokeless tobacco is necessary.
Recently Bhutan has also banned the import for sale of all tobacco products, since none of these are produced within the country, and production is banned. Nevertheless, in Bhutan there is an increasing demand for smokeless tobacco that laws alone cannot reduce. Import for personal use is allowed, within limits and import duty must be paid. The Ministry of Health in Bhutan is using the broadcast and print media to inform the public about the hazards of tobacco use in all its forms. [15]
In most countries, the process of making a law to ban the import of tobacco products is likely to be more complex than it has been in Thailand and Bhutan. These examples, however, highlight the importance of seeking understanding and cooperation between the Health and Finance Ministries.
| Why smokeless tobacco needs special attention | | |
Smokeless tobacco needs as much attention in control efforts as smoking forms of tobacco for a number of reasons:
- High prevalence of use in the Region
- High prevalence of spitting leading to an unhygienic environment
- Preference by rural populations and lower socio-economic groups
- High disease burden
- Conflicts with Millennium Development Goals
Prevalence
Adult prevalence of smokeless tobacco use varies greatly among the countries in SEAR but is substantial in at least six countries of the region, as shown in [Figure 1]: for men it varies from 1.3% in Thailand, [12] to 32.9% in India [16] and 51.4% in Myanmar; [17] in women it ranges from 4.6% in Nepal, [17] to 27.9% in Bangladesh. [18] The high rates of use may occur because (except for DPR Korea) all the SEAR countries lie in the "betel quid belt", the area where betel quid has been used for many centuries. In fact, in four of these countries there is extensive use of smokeless tobacco products in conjunction with betel quid.  | Figure 1: National smokeless tobacco prevalence in men and women in six countries of SEAR [12,16,17,18]
Click here to view |
The prevalence of betel quid chewing in particular has recently been studied in parts of Asian countries in adults aged ≥ 15 years. Among the three SEAR countries surveyed, the prevalence of betel quid chewing with tobacco was found highest in Nepal (men: 43.6%; women: 34.9%), followed by Indonesia (men: 10.4%; women: 31.7%) and lastly Sri Lanka (men: 6.4%; women: 3.2%). In Sri Lanka, the prevalence of betel quid chewing without tobacco was considerably higher than chewing with tobacco, whereas in the other two countries, chewing betel quid with tobacco predominated. [19]
According to results of the Global Adults Tobacco Survey (GATS) in India, tobacco with lime (khaini) is the most common form of tobacco chewing. This can be prepared by the user, the vendor or purchased as a ready-made product Khaini is used by 18% of men and 5% of women. The next most commonly used product is gutka (13% of men and 3% of women) followed by betel quid with tobacco (8% of men and 5% of women). These data show how greatly gutka has made inroads into the traditional pattern of smokeless tobacco use. [16]
There are various other tobacco products used in India that contain pieces of areca nuts along with tobacco and lime and such mixtures are also commonly used. Application of dry snuff type products (e.g. tapkeer, gul, masheri, red tooth powder), and paste like products (e.g. gudakhu, tobacco tooth paste or creamy snuff) on the gums and teeth is common in India. In India, at present smokeless tobacco is used by 25.9% of all adults (32.9% of men and 18.4% of women). [16]
Further data from the WHO STEPS surveys characterizing the smokeless tobacco problem among adults in specific rural and urban areas of different parts of SEAR: Men, 5.4% to 39.6% in urban areas; 6.5% to 67.6% in rural areas; women, 0.9% to 17.6% in urban areas; 1.6% to 41.6% in rural areas [17] [Table 1].  | Table 1: Prevalence and pattern of smokeless tobacco use among adults at different sub-national sites in SEAR
Click here to view |
Prevalence rates of smokeless tobacco among youth aged 13-15 years in seven SEAR countries are available from the Global Youth Tobacco Surveys (GYTS). For boys it varies from 5.8% in Bangladesh to 14.1% in India; for girls it varies from 2.7% in Myanmar to 6.0% in India [20] [Table 2].  | Table 2: Prevalence of current smokeless tobacco use among students aged 13-15 years at national level in selected Member States of the South-East Asia Region
Click here to view |
Smokeless tobacco use requires spitting. A high prevalence of smokeless tobacco use leads to a high prevalence of spitting, creating an unaesthetic and unhygienic environment, which may lead to the spread of diseases, including tuberculosis. However, a ban on spitting could, without a complete health message, lead to a swallowing of the juices, which results in higher rates of upper aerodigestive cancer. In Nepal, around 95% of chewers of betel quid with tobacco typically swallow the juices. [19] In Singapore, where spitting is strictly banned, small bags are offered to betel quid chewers for spitting into.
Increasing Trend in the Region
The fact that children and youth are seen in large numbers taking up smokeless tobacco is a powerful indicator of an increasing trend. A few examples are given here.
In an urban survey carried out in 32 schools in New Delhi and Chennai, sixth graders were 2-4 times more likely than eighth graders to currently use tobacco (in the last 30 days). Chewing tobacco was the form most commonly used and 19% of sixth graders versus 6.8% of eighth graders had ever used it, while 4.5% of sixth graders versus 1.6% of eighth graders were current tobacco chewers. The sixth graders were also psychologically more predisposed towards tobacco use as measured by psychosocial risk factors. This finding raised the serious question as to whether younger children were getting more exposed to pro-tobacco messages even after a complete ban on advertisement of tobacco products. [21]
A study in rural Maharashtra found current adolescent use (15-19 years) of smokeless tobacco (in the last 30 days) to be quite common (68.3% among boys and 12.4% for girls). Age of initiation was early as 8-10 years for boys and 12-13 years for girls. The main forms of tobacco used were dry snuff for teeth cleaning (especially for girls), tobacco with lime (khaini), kharra or mawa or gutka (all consisting of tobacco with areca nut and lime, etc). Influences to use tobacco included parental use, peer pressure, advertisements and colorful packaging. [22]
A study among urban adolescents in Pokhara, Nepal, found that pan masala and gutka were the most commonly used products, followed by cigarettes and khaini (also called Surti). Ever use of pan masala/gutka was 51.4% among boys, 31.3% among girls. The mean age of initiation to tobacco was 13 years, with nearly one fifth initiating below the age of 10 years. [23] Nepal has identified the need to focus on youth to reduce the use of smokeless tobacco products. [24]
For most of the countries there is a lack of successive surveys with comparable methodology usable for investigating trends in smokeless tobacco use, but those available for Myanmar and Sri Lanka illustrate an increasing trend.
In Myanmar, the Global Youth Tobacco Surveys of 2001 and 2007 show that cigarette smoking has decreased among youth and adults, but use of other tobacco products has increased. [25] In Myanmar, Sentinel Prevalence Surveys of 2001, 2004 and 2007 show that among adults prevalence of smoking has been decreasing, while smokeless tobacco use has been increasing.
In Sri Lanka also, the GYTS results show that from 2003 to 2006, cigarette smoking had decreased, while other types of tobacco use had increased, [26] most likely to be mainly smokeless forms.
Other evidence for increased smokeless tobacco use comes from trade information on increasing trade. For example, there is considerable trade of Indian smokeless tobacco products flowing legally as well as illegally into Myanmar, [27] Nepal, Sri Lanka, Bangladesh, [28] and Bhutan. [29]
Usage in the disadvantaged groups
The poorest individuals are the ones most likely to be regularly using smokeless tobacco. [16],[18] In a cross-sectional study in Myanmar, the lowest income users of smokeless tobacco were spending 20% of their income on tobacco, potentially leading to deprivations. [27]
Betel quid chewing is more common in rural areas of SEAR countries. [3],[30] In the GATS Survey in India, the prevalence of smokeless tobacco use was nearly twice as high in rural areas compared to urban ones; it was higher in those without formal education compared to those with secondary education and above (twice as high in men, eight times higher in women). [16] In Thailand, use of smokeless tobacco was close to twice as high in rural men and four times higher in rural women than in their urban counterparts. However in Bangladesh there was little difference between urban and rural prevalence of smokeless tobacco. [18]
Women over 65 years of age had the highest prevalence of smokeless tobacco use of all women in the three GATS surveys: In 64.1% in Bangladesh, [18] 30.2% in India, [16] and 32.9% in Thailand. [12]
The use of betel quid (with or without tobacco) and of smokeless tobacco has commonly been found to be initiated by people seeking relief from dental complaints, such as toothache, or gastrointestinal symptoms. Lack of access to dental services and health care are cited as reasons for initiation of tobacco use. It is likely that the persistence of betel quid chewing in rural areas is partly due these reasons. [31] Betel quid chewing is actually associated with a reduction in dental caries, but at the same time, as increase in periodontitis and tooth loss. [32] While the rural poor in Thailand have access to as little as 2% of dental services available in the country, [33] the use of smokeless tobacco use in rural Thailand is as low as 1.5% in men and 8.3% in women. [12] This low prevalence may be due in part to a history of health education in schools about the harms of smokeless tobacco use [9] in this highly literate country, as well as to cigarette smoking having overtaken betel quid chewing.
The poorest people are the most nutritionally disadvantaged, who can least defend themselves from assault on the body by the carcinogens and other harmful chemicals in smokeless tobacco; they are thus more at risk of tobacco related cancers. [34]
Adverse Health Consequences
From its assessment of epidemiological evidence, the IARC has found sufficient evidence that smokeless tobacco causes oral cancer and pancreatic cancer, [3] that betel quid with tobacco causes cancer of the pharynx and esophagus and that betel quid without tobacco can cause oral cancer. [30] Chewing tobacco by itself as used in South Asian countries may pose a higher cancer risk than betel quid with tobacco at least for some anatomical sites, e.g., oropharynx. [35]
A recent international review on tobacco and cancer summarizes the available evidence on increased risks of cancers caused by smokeless tobacco use: in India over half of oral cancers are caused by smokeless tobacco use; a summary of epidemiological studies in the USA and Asia show an overall relative risk of oral cancer of 2.6 (95% Confidence Interval[CI]: 1.3-5.2). [36]
Excess risk of esophageal cancer has also been found in smokeless tobacco users from northern Europe, [36] as well as users in SEAR. For example, in a matched case-control study of esophageal cancer in Assam, India, chewers of chadha, a type of plain tobacco, more than a three-fold higher risk for esophageal cancer (P<0.001), adjusted for smoking and alcohol. Chewers of different kinds of betel quid (red/green areca nut or fermented underground) with different chewing tobacco products also experienced increased odds ratios (2.2 - 7.1), which were mostly significant with P<0.01 or P<0.001. [37]
Apart from cancer, smokeless tobacco also contributes to cardiovascular diseases. [3] For example, in a cohort study in India, the risk ratio for mortality due to diseases of the circulatory system (ICD10: I00-I99) among nonsmoking women who used smokeless tobacco was 1.19 (95% CI: 1.02-1.38) and for ischemic heart disease, the risk ratio was 1.25 (95% CI: 1.05-1.49). [38]
Smokeless tobacco and the UN Millennium Development Goals
Smokeless tobacco use conflicts with the Millennium Development Goal (MDG), number 4, to reduce child mortality and MDG number 5, to improve maternal health. [39] This is because use of smokeless tobacco [3] and or areca nut [30] during pregnancy increases risk of low birth weight. For example in a population based cohort study of 1167 pregnant women followed up in Mumbai, the adjusted risk ratio for low birth weight among nonsmoking women who used smokeless tobacco was 1.6 (95% CI: 1.1-2.4) [40] and for still birth, 2.6 (95% CI: 1.4-4.8). [41] Families in India with members who regularly buy tobacco often suffer from chronic deprivation of foods important for the growth and survival of children, such as milk and fruits, as found from an analysis of National Sample Survey data on consumption patterns for 1999-2000. [42]
Most SEAR countries grow tobacco leaf, the basic ingredient for smokeless tobacco. The main producers are India, Bangladesh and Indonesia. India is one of the largest producers of tobacco in the world and a large proportion of tobacco grown in India is used in smokeless forms.
Countries in SEAR that manufacture smokeless tobacco products include India, Bangladesh and Myanmar. All three of these countries produce zarda and khaini, in addition to products unique to their countries.
India is the largest smokeless tobacco exporting country in SEAR, in both leaf form and as products. In 2004-05, Gujarat exported 7785 tons of unmanufactured chewing tobacco leaf to Yemen. [43] In 2003-04, some 29 countries imported chewing tobacco products from India. [44] By 2009-10 more than 48 countries imported such products. Among them, Nepal officially imported 231 tons of chewing tobacco products during 2009-10. [45] According to its own records, Nepal was importing substantial quantities of khaini and zarda as early as 1997 and 1998. [46]
The Tobacco Board of India promotes the smokeless tobacco industry in India and participates in international trade fairs and exhibitions to promote the export of Indian tobacco products. For example it participated in such events in Indonesia and Thailand during 2009-10. [45]
| Smokeless tobacco control policy - where we stand
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Using the six strategy concepts of the MPOWER measures based on the WHO Framework Convention on Tobacco Control, we indicate the status of tobacco control in the countries of the South-East Asia Region.
Monitoring: So far, most of the countries have started monitoring both smoking and smokeless tobacco use in their populations through surveys of adults and youth. Ten out of the eleven countries in SEAR, excepting DPR Korea, have conducted Global Youth Tobacco Surveys. With regard to monitoring of adult tobacco use, countries that are monitoring only smoking, but not smokeless tobacco, include Indonesia and Maldives. Three other countries in SEAR are yet to start monitoring any form of adult tobacco use (Bhutan, Timor Leste and DPR Korea). Monitoring of policy under the Framework Convention on Tobacco Control (WHO FCTC) [47] has been done formally by Bhutan (2010), [15] Myanmar (2009), [25] Nepal (2010) [24] and Sri Lanka (2009) [26] with publication of their Brief Profiles on Tobacco Control. NGOs in India have prepared a report on the implementation of the WHO FCTC in India. [48] All five of these documents mention smokeless tobacco and related policies in the respective countries.
Protecting people: Like smoking in public places, spitting is a behavior of smokeless tobacco users that the public needs to be protected against, as it is unhygienic. Spitting has been banned on streets and in other public places in some parts (mainly cities) of Bangladesh, Myanmar and India (Delhi, Mumbai, Shimla, and in the State of Rajasthan). Enforcement, however, is difficult, especially with limited resources for deploying manpower.
Offering help to quit tobacco: Nineteen Tobacco Cessation Centers (TCCs) have come up in India since 2002, with the support of WHO India. Apart from their work with individual patients in diverse urban settings, they also conduct outreach into surrounding communities. The TCCs have recently become training centers as well, for preparing personnel for new TCCs. Thailand has developed an extensive network of tobacco cessation services in hospitals primary care centers and in communities thanks to the mobilization and training provided by ASH Thailand and the Thai Physician Alliance Against Tobacco.
Warning about the dangers of tobacco use: Health warnings on smokeless tobacco products are implemented in India, in spite of a lot of interference from the tobacco industry. [49] Tobacco products for export from India are not required by Indian law to bear health warnings, but Bhutan, where commercial import is not allowed, has rules that require any tobacco product brought in for personal use to bear a health warning from the country of the origin. In Thailand, shredded tobacco packages, sold for making roll-your-own cigarettes, and sometimes used for chewing, bear graphic health warnings indicating that smoking causes throat cancer, but does not mention what can happen to chewers. Except for India and Bhutan, other countries in the Region have not yet formulated rules for health warnings on smokeless tobacco products.
Enforce bans on tobacco advertising: India, Sri Lanka, Thailand, Bhutan, Maldives, Myanmar have banned smokeless tobacco advertisements, however, implementation is inadequate, especially in view of the common use of indirect advertisements. [50] Bangladesh, Indonesia and Timor-Leste lack policies banning smokeless tobacco advertisements and as a consequence, around 70% of adults in Bangladesh noticed advertisements for smokeless tobacco products in 2009, according to the Global Adult Tobacco Survey (GATS). [18]
Raise Taxes on Tobacco: India has generally been legislating raises in taxes on smokeless tobacco products every few years. [51] Excise tax evasion is, however, rampant in India, despite efforts by the excise officials. Smokeless tobacco products are taxed less than smoking products.
| The way forward | | |
By implementing the WHO Framework Convention on Tobacco Control and following WHO recommended MPOWER measures, countries can reduce the use of tobacco and consequent diseases and premature deaths. [8] Periodic monitoring with a standard protocol and questionnaire will be very helpful in planning tobacco control including smokeless tobacco control. Many countries in the Region have started using standard Tobacco Questions for Surveys (TQS) based on the GATS.
The unhygienic aspect of spitting also needs to be highlighted to the public. This is one of the recommendations in the Smokeless Tobacco Expert Group Consultation in WHO SEARO.
An expanded health care system, where people can also find effective help and advice for quitting smokeless tobacco is needed. It is heartening that countries in the Region are making efforts in this direction. Health education campaigns as well as strong, rotating graphic pictorial and textual health warnings on packages of smokeless tobacco will be effective. Bans on advertising in mass media as well as at point of sale will help to reduce the appeal of smokeless tobacco products. Hikes in taxes on smokeless tobacco products will make them less attractive to consumers, who may cut down on their use.
Banning the manufacture and sale of smokeless tobacco products is a strategy already followed by Thailand and Bhutan. Such a policy is being considered in India, after a National Consultation on Smokeless Tobacco held in April 2011, organized by the Ministry of Health and Family Welfare. Interim measures are being considered, such as licensing of tobacco retail outlets, to prepare the way for a ban. Thought is also being given to a likely rise in demand for cessation services as well as to dealing with economic consequences of a ban, such as loss of revenue, loss of livelihood and illegal trade.
In view of the threat to public health posed by the export of smokeless products from manufacturing countries to non-manufacturing countries in SEAR, countries need to strategize how they could protect their people from smokeless tobacco products entering from other countries under prevailing trade laws. Several options are available:
- Non-manufacturing countries could avail of the opportunity to ban the import of smokeless tobacco products (as done by Thailand in 1992 and more recently by Bhutan) and adopt anti-smuggling measures.
- Countries where smokeless tobacco products are currently manufactured, can refuse to import those types of smokeless products which they do not manufacture, that is, if they are totally unlike other tobacco products they manufacture within their borders. An important example of this would be gutka, one of the most harmful products. They can also take action now to ban the manufacture of any smokeless tobacco product types not currently made within their borders. [52] Iran and Tanzania had banned the import of Indian chewing tobacco products on health grounds during 2006-07, [53] leading to no import in these countries the following year. [54]
- Countries can take the lead in keeping both tobacco and areca nut (unmanufactured and manufactured products) on their "Sensitive Lists" for trade purposes within their regional trade associations (SAARC, ASEAN), which means that they may restrict free trade of these commodities with countries within those regions. [55],[56]
- For regional control of trade and cross border advertising, interagency partnerships need to be strengthened within and among countries, and intergovernmental negotiations are needed to find solutions.
- For tackling the issues of interregional trade of smokeless tobacco products, collaboration between WHO member countries would be helpful. Among the regions, most of the efforts are needed in the Eastern Mediterranean Region, because at present most exports from SEAR (India) go to EMR countries, but AFR, AMR and EUR countries also need to be contacted since some of them receive legal and/or illegal imports.
- In the General Obligations (Article 5) of the WHO FCTC, [47] Parties are required to act to protect their tobacco control policies from commercial and other vested interests of the tobacco industry. NGO representatives in India have voiced the need for the Parties to the WHO FCTC to adopt a code of conduct for government officials and its representatives that would govern their dealings with the tobacco industry. [57]
In conclusion, national policies in SEAR countries need to take the threat of smokeless tobacco into account in a multifaceted manner. Smokeless tobacco has to be controlled along with tobacco smoking with the view that they are both two parts of one whole problem.
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[Figure 1]
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