Year : 2011 | Volume
: 55 | Issue : 3 | Page : 151--154
Tobacco epidemic in South-East Asia region: Challenges and progress in its control
Jai P Narain, Dhirendra N Sinha
WHO Regional Office for South-East Asia, New Delhi - 110 002, India
Jai P Narain
WHO Regional Office for South-East Asia, New Delhi - 110 002
|How to cite this article:|
Narain JP, Sinha DN. Tobacco epidemic in South-East Asia region: Challenges and progress in its control.Indian J Public Health 2011;55:151-154
|How to cite this URL:|
Narain JP, Sinha DN. Tobacco epidemic in South-East Asia region: Challenges and progress in its control. Indian J Public Health [serial online] 2011 [cited 2020 Oct 28 ];55:151-154
Available from: https://www.ijph.in/text.asp?2011/55/3/151/89940
Strong and unequivocal evidence that smoking causes lung cancer and other illnesses dates back to 1950s when seminal papers on the subject were published by Richard Doll and Bradford Hill based on the retrospective and prospective epidemiological studies conducted by them. ,, Thereafter, many other studies have also demonstrated the harmful effects of smoking.  In spite of the clear evidence, today the tobacco epidemic still remains one of the biggest public health threats and the leading cause of preventable mortality the world over. Nearly six million people die each year from tobacco use and exposure to second-hand smoke worldwide.  If action is not taken to check the epidemic, the figure will reach eight million by 2030 and most of them will take place in developing countries.
Burden in the South-East Asia Region
The burden in the SEA Region is one of the highest among the WHO regions and tobacco use a growing public health problem.  It kills over 1.3 million people annually. The region is home to over 400 million tobacco users and in particular, prevalence of smoking among men in many countries of the Region is high and among female smokeless tobacco use is popular. The young people are particularly vulnerable and they use non cigarette tobacco products mostly. 
In addition, passive or secondhand smoking puts unsuspecting populations at risk of harm following exposure to tobacco due to no fault of theirs. This is also a social menace and a major health problem. For example, nearly three in five adults are exposed to secondhand smoke (SHS) in homes as well as in public and work places in Bangladesh.  A study published recently estimates that as many as 135000 people die each year in the Region due to exposure to SHS. 
In the SEA region, tobacco is used in a variety of ways, from smoking cigarette or bidi (rolled cigarette) to smokeless tobacco use in various forms such as chewing khaini or sucking gutka, applying gul, gudaku etc as dentifrice and gargling as tuibur. Gutka is especially popular among youth which is usually available in small sachets or in a pouch form and easily accessible.  The prevalence of smokeless tobacco use is high in a few countries of the SEA Region such as Bangladesh, India, Myanmar, Nepal and Sri Lanka. It is estimated that nearly 250 million adults are users of smokeless tobacco in the Region.  Smokeless tobacco use is considered to be even more addictive than smoking form, attributed to the presence of elements like nitrosamines. The complex nature of tobacco use with both smoking and smokeless forms is a major challenge for implementing tobacco control measures.
Although women are commonly found to be using smokeless tobacco, the recent rising trend of smoking among them is a grave cause of concern in the Region. In addition, young people are at great risk of smoking resulting from peer pressure and misconception regarding glamour associated with it and the aggressive marketing tactics used by the tobacco industry.
Health, social and economic consequences
Tobacco is clearly the most potent risk factor causing noncommunicable diseases (NCDs); as many as 40% of all tobacco cancer deaths are linked with smoking.  It gives rise to a wide range of illnesses affecting various organs such as lung cancer, chronic bronchitis, chronic lung diseases among men and breast cancer, premature delivery, pregnancy related complications among women. As outlined in a paper in this journal, in SEAR countries, about 55% of total deaths are due to NCDs with highest in Maldives (79.4%) and low in Timor-Leste (34.4%). Premature mortality due to NCDs in young age is high in the region with 34% of the deaths due to NCDs occurring below the age of 60 years, and 48% below the age of 70 years. Among males who died of cancer, the commonest site was lung (17%), followed by mouth and oropharynx (15%), and liver (7.5%). In 2008, about 1.1 million people died of cancer in the Region.
Besides health, smoking also has major socio-economic and developmental dimensions. Tobacco users who die prematurely deprive their families of income, raise the cost of health care (much of which is out-of-pocket expenditure), and undermine chances of economic advancement, pushing the family into poverty. Economic studies show that people are often suffering significant monetary losses as significant part of their income is used for tobacco products.  In Myanmar, tobacco users in the lowest income group spend about as high as 33% of their income on tobacco. The poorest households in Bangladesh spend almost 10 times as much on tobacco as on education. It is estimated that tobacco consumption pushes approximately 15 million people into poverty in India. The argument that tobacco tax generates revenues for the government is countered by the fact that the cost incurred to society due to tobacco use exceeds the amount gained as revenue from tobacco. Some studies of the Region show that cost of treatment of diseases attributable to tobacco use was more than double of the revenue that governments received from tobacco taxation. Tobacco use induced morbidity and mortality cause considerable economic loss in addition to enormous sufferings, physical and emotional distress and the loss due to death of tobacco users to the families and societies.  In addition, income spent on tobacco deprives families of nutrition, education and health care, pushing them further in the cycle of poverty.
Tobacco also is a part in the culture and tradition of many countries of the Region. Use of tobacco is culturally and socially accepted and is integral part of social gatherings and religious ceremonies in some countries of the Region. Offering tobacco products to guests is a form of greeting and sharing among people is seen as a symbol of companionship and unity. Also, young people consider smoking as a symbol of independence and coming of age. However, people in some communities equally keep away from consuming tobacco because of the negative perception and religious views they have towards tobacco. Thus, tobacco use is intimately woven into the social and cultural fabrics of the people of South-East Asia.  The governments and other players may need to first understand the social aspects of tobacco use while developing any policy and programmatic interventions to address the tobacco related issues.
WHO Framework Convention on Tobacco Control (FCTC) as an international framework for tobacco control: Progress in implementation and challenges
In light of the fastest growing epidemic of smoking and the tobacco manufacturers targeting developing countries, especially people of younger age, the Fifty-sixth World Health Assembly in 2003 adopted a landmark Resolution WHA 56.1 calling for an international regulatory framework on tobacco control. The Convention entered into force in 2005. The resolution is a remarkable achievement and represents a new approach in international health cooperation using a global legal framework to address a globalized epidemic. It recognizes the importance of international cooperation and helping low- and middle-income countries to meet their treaty obligations. It has catalyzed actions across countries and facilitated new policies and legislations in the member countries. Currently, 174 countries are party  to the Framework Convention and are legally bound to fulfill its obligations by implementing the provisions of the Convention.
The counties in the Region are in different stages of scaling up the implementation of the Framework Convention's provisions. Ten Member States have ratified the Framework Convention, and with exception of Indonesia and Timor-Leste, nine countries have already put in place comprehensive tobacco control legislations. The WHO FCTC is the first ever global public health treaty developed and contains, important provisions.  Apart from this, there is also a strategic tool called PMOWER. 
M- Monitor tobacco use and prevention policies (surveillance, research and monitoring)P - Protect people from tobacco use (protection from secondhand smoke)O- Offer help to quit tobacco use (tobacco dependence and cessation)W- Warn about dangers of tobacco (packaging and labelling of tobacco products)E - Enforce bans on tobacco advertising, promotion and sponsorshipR - Raise taxes on tobacco (price and tax measures to reduce the demand for tobacco.)
MPOWER is a package of technical measures and resources, each of which reflects one or more of the demand reduction provisions of the WHO FCTC. It has been developed to help countries build their capacity to implement these provisions. The successful implementation of these measures will ultimately play a key role in reducing the cancer burden in these countries. MPOWER helps countries in monitoring the implementation of the Framework Convention.
All countries in the Region have adopted the MPOWER measures to implement tobacco control programmes effectively. Some of the programmes include health education and awareness campaigns on tobacco control, integration of tobacco issues into school health programmes and establishment of wide-ranging tobacco cessation services. 
The Framework Convention recommends 30%-50% coverage for health warnings on tobacco product packages. Some Member countries in this Region have gone beyond the Convention's provisions. Thailand has recently upgraded graphic health warnings to cover 55% of the front and back surfaces  and the newly approved tobacco control act of Nepal also stipulates the requirement of health warning messages covering at least 75% of the surface area of tobacco packages. Another example of unique tobacco control effort is in Bhutan where all sorts of tobacco production, distribution, sale and advertisements are completely banned. The Convention has also led some countries to use tobacco tax revenue to fund health care innovatively. India is using a 10% cess on tobacco for the National Rural Health Mission  while Thailand is using 2% of its tobacco and alcohol tax for health promotion. 
Civil Societies have also played important role in tobacco control in the Region.  Chandigarh and Chennai smoke free initiative are only two examples of the best practice of Government and civil society collaboration in tobacco control. 
The WHO Regional Office and the country offices are at the forefront of coordinating and supporting the tobacco control efforts and activities in Member countries. The WHO staff provide technical support to Member States in surveillance, monitoring and research, formulating legislation, implementing the treaty, adopting best practices and protecting public health policies from the vested interest of the tobacco industry.
Opportunities ahead to make a difference
Although the WHO FCTC is a relatively new treaty, it reflects the power of prevention. It has a robust system of implementation review. The Convention's Conference of Parties has adopted a number of guidelines to assist countries to implement the key articles of the Convention and the work is underway to develop some more guidelines as well as a protocols. However, there are also many challenges relating to its implementation.
The monitoring report states clearly that the full preventive power of the Convention is far from being realized. For example, all tobacco products are not covered under national tobacco control legislation in all Member countries, and big gaps exist in taxation levels on different tobacco products in many countries. Furthermore, 100% smoke-free policy in public places has also not been enforced in many Member countries of the Region. These challenges must be overcome on an urgent basis in order to get the maximum benefit from tobacco control and assist in reducing morbidity and mortality associated with tobacco-related diseases.
Clearly, tobacco control is a multi-sectoral issue and it needs comprehensive and concerted action from all relevant sectors. The WHO FCTC recognizes the multi-sectoral nature of tobacco control and suggests action in the domain of legal, health, fiscal, educational, research and surveillance activities. Tobacco control efforts need to be integrated into other health programmes, such as prevention and control of noncommunicable diseases, health promotion, maternal and child health, school health, adolescent health, TB control and also poverty alleviation initiatives.
In view of strengthening tobacco control measures, Member States in the Region must prioritize tobacco control goals and indicators, seek alternative methods to finance tobacco control and commit necessary human and financial resources to tackle the tobacco epidemic successfully. It's critical that governments and tobacco control partners work together with the community and amplify their efforts to control the epidemic of tobacco use. The full and sustained implementation of tobacco control can contribute greatly towards protecting present and future generations from the devastating health, social, environmental and economic consequences of tobacco.
|1||Doll R, Hill AB. Smoking and carcinoma of the lung. Preliminary report. BMJ 1950;2:739-48. |
|2||Doll R, Hill AB. The mortality of doctors in relation to their smoking habits. BMJ 1954;228:1451-5. |
|3||Doll R, Hill AB. Lung cancer and other causes of death in relation to smoking. BMJ 1956;2:1071-81. |
|4||Peto R, Chen ZM, Boreham J. Tobacco-the growing epidemic. Nat Med 1999;5:15-7.|
|5||World Health Organization. WHO report on the global tobacco epidemic 2011: Warning about the dangers of tobacco. Geneva: WHO; 2011. |
|6||Thakur JS, Garg R, Narain JP. Tobacco use: A major risk factor for non communicable diseases in south-east Asia region. Indian J Public Health 2011;55:155-60. |
|7||World Health Organization. Regional Office for South-East Asia. The WHO FCTC Indicators: Global Tobacco Survey, 2009. New Delhi, India, 2011. |
|8||Palipudi KM, Sinha DN, Choudhury S, Mustafa Z, Andes L, Asma S. Exposure to second-hand smoke among adults in Bangladesh. Indian J Public Health 2011;55:210-9. |
|9||Oberg M, Jaakkola MS, Woodward A, Peruga A, Prüss-Ustün A. Worldwide burden of disease from exposure to second-hand smoke: A retrospective analysis of data from 192 countries. Lancet 2011;377:139-46. |
|10||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. |
|11||Sinha DN, Pallipudi KM, Rolle I, Asma S, Rinchen S. Tobacco use among youth and adults in member countries of south-east Asia region: Review of findings from surveys under global tobacco surveillance system. Indian J Public Health 2011;55:169-76. |
|12||World Health Organization. Regional office for south-east Asia. Risk factors for Chronic Noncommunicable diseases. Capacity strengthening for prevention and control of noncommunicable diseases in south-east Asia region. New Delhi, India, 2011.|
|13||World Health Organization. Systematic review of the link between tobacco and poverty. Geneva, 2011.|
|14||Kyaing NN, Islam A, 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. |
|15||Parties to the WHO Framework Convention on Tobacco Control. WHO FCTC website. Available from: http://www.who.int/fctc/signatories_parties/en/index.html). [Last accessed on 2011 Aug 9].|
|16||World Health Organization. WHO Framework Convention on Tobacco Control. Geneva, 2005. |
|17||World Health Organization. Regional office for south-east Asia. Profile of Implementation of WHO Framework Convention on Tobacco Control in the south-east Asia region. New Delhi, India, 2011.|
|18||Vathesatogkit P, Charoenca N. Tobacco control: Lessons learnt in Thailand. Indian J Public Health 2011;55:228-33. |
|19||Kaur J, Jain DC. Tobacco control policies in India: Implementation and challenges. Indian J Public Health 2011;55:220-7.|
|20||Thai Health Promotion Foundation. Health Promotion Foundation Act, B.E. 2544, 2001.|
|21||Burning Brain Society. Website of Burning Brain Society. Available from: http://www.burningbrain.org. [Last accessed on 2011 Aug 9]. |
|22||Kashiwabara M, Arul R, Goswami H, Narain JP, Armada F. Local governments and civil society lead breakthrough for tobacco control: Lessons from Chandigarh and Chennai. Indian J Public Health 2011;55:234-9.|