|Year : 2020 | Volume
| Issue : 1 | Page : 16-21
Tracking progress of tobacco control in Pakistan against the MPOWER package of interventions: Challenges and opportunities
Haleema Masud1, Paramjit Gill1, Sharifah Sekalala2, Oyinlola Oyebode1
1 Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, England, UK
2 Warwick Law School, University of Warwick, Coventry, England, UK
|Date of Submission||30-Oct-2019|
|Date of Decision||05-Dec-2019|
|Date of Acceptance||20-Mar-2020|
|Date of Web Publication||31-Mar-2020|
Ms. Haleema Masud
Farm-House, Gibbet Hill Campus, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, England
Source of Support: None, Conflict of Interest: None
MPOWER is an evidence-based package of the six most effective demand reduction interventions to reduce tobacco use. Global evidence shows that introduction of this package has accelerated and strengthened tobacco control worldwide with over 5 billion people living in 136 countries covered by at least one of these key interventions. This paper comments on how tobacco control laws in a low and middle income country, Pakistan, are meeting the MPOWER package provisions and what the challenges and opportunities for tobacco control are in the country. Pakistan is home to over 24 million tobacco users consuming a variety of tobacco products including 10 million smokeless tobacco users. Pakistan has introduced several laws to meet its international commitments under the framework convention against tobacco control and MPOWER package. However, gaps in existing policies, poor law enforcement, and a conflicting political economy of tobacco in the country pose major challenges for effective tobacco control. The changing political environment with renowned public health activists in current government, an active and independent judiciary, increasing use of social media, and a dynamic civil society offer opportunities to strengthen its efforts for effective policy actions against tobacco use.
Keywords: Framework convention against tobacco control, MPOWER, tobacco control
|How to cite this article:|
Masud H, Gill P, Sekalala S, Oyebode O. Tracking progress of tobacco control in Pakistan against the MPOWER package of interventions: Challenges and opportunities. Int J Non-Commun Dis 2020;5:16-21
|How to cite this URL:|
Masud H, Gill P, Sekalala S, Oyebode O. Tracking progress of tobacco control in Pakistan against the MPOWER package of interventions: Challenges and opportunities. Int J Non-Commun Dis [serial online] 2020 [cited 2021 Apr 19];5:16-21. Available from: https://www.ijncd.org/text.asp?2020/5/1/16/281666
| Introduction|| |
Globally, there has been significant progress in tobacco control over last decade using evidence based measures listed in the World Health Organization's (WHO) framework convention on tobacco control (FCTC). Collectively, these interventions have reduced global smoking prevalence by almost 30% between 1990 and 2015. However, the progress has not been uniform across countries. Tobacco use disproportionately affects low and middle income countries (LMICs) where 80% of the current users live. Being a major risk factor for noncommunicable diseases (NCDs) which are responsible for over two thirds of deaths in LMICs, tobacco control measures need to be prioritized in these countries, which include Pakistan. It is important to monitor progress of LMICs countries against the FCTC guidelines and identify areas which need strengthening in legislation or implementation.
The WHO introduced a package of six demand reduction interventions in 2007 to help FCTC member states in prioritizing and implementing FCTC measures. This package, named MPOWER, consists of the six most effective interventions in reducing tobacco consumption; namely: (M) monitoring tobacco use and prevention policies; (P) protecting people from tobacco smoke; (O) offering help to quit tobacco use; (W) warning about the dangers of tobacco; (E) enforcing bans tobacco advertising, promotion and sponsorship; and (R) raising taxes on tobacco. Global evidence shows that introduction of this package has speeded up and strengthened FCTC implementation. The latest WHO report on monitoring the tobacco epidemic highlights that over 5 billion people living in 136 countries are covered by at least one of these key interventions. This number has grown by four times since the introduction of the MPOWER package. The major step in this regard is introduction of laws and regulation supporting the MPOWER package of interventions. This paper comments on how tobacco control laws in a LMIC, Pakistan are meeting the MPOWER package provisions and what are the challenges and opportunities for tobacco control in the country.
Pakistan is home to over 24 million tobacco users including 10 million smokeless tobacco consumers who use a variety of tobacco products. This enormous tobacco burden is associated with huge morbidity and mortality in the country. Although there is a lack of empirical data on costs of tobacco-related diseases in Pakistan, some estimates suggest an annual loss of over 100 billion rupees to treat tobacco-related illness. Pakistanis directly spend over 250 billion rupees in purchasing tobacco products, this money could be used for food, health or education. The government of Pakistan has been engaged in tobacco control since its independence and initially introduced two small scale laws- the Punjab Tobacco Vend Act, 1958 (requiring a licence to sell manufactured tobacco products in urban areas) and the West Pakistan Juvenile Smoking Ordinance, 1959 (which restricted sale of tobacco products to minors and banned smoking by minors in public places). However, both of these laws and the various laws that were subsequently introduced laws were not implemented in the way planned. Tobacco control laws became focused and strengthened after Pakistan became a party to the FCTC in 2004 and the national tobacco control cell was established in 2007. The Government of Pakistan makes rules and issues several statutory regulatory orders (SRO) from time to time to communicate advances and changes in the regulations. This paper analyses current tobacco related laws to track Pakistan's compliance with MPOWER provisions both in terms of contents and implementation with an aim to highlight the areas which need strengthening in order to meet the legal FCTC commitments.
This paper used the seventh WHO report on the global tobacco epidemic to define the provisions of the MPOWER package for tracking progress of Pakistan. Existing policies on tobacco control were accessed through the Tobacco Control Cell's website and Ministry of Finance's website while data on level of implementation was retrieved from the latest MPOWER report, compliance studies, media reports, annual reports submitted to the FCTC secretariat and the most recent national tobacco use surveys.
| Findings|| |
[Table 1] provides a snapshot of compliance of Pakistani laws against the provisions of the MPOWER package and also details their current implementation status.
|Table 1: Tracking progress of tobacco control in Pakistan against the MPOWER package of interventions|
Click here to view
Monitoring tobacco use and prevention policies
Pakistan is applauded for implementing the “M” measures (monitoring of tobacco use policies) in the MPOWER package to the highest level. Pakistan has historically monitored tobacco use as part of the national demographic and health surveys dating back to 1990s. Recent progress is measuring tobacco use among youth include using the Global Youth Tobacco Surveys in 2004, 2009 and 2013. Pakistan successfully implemented its first Global Adult Tobacco Survey (GATS) in 2014 to give a situation analysis of tobacco use. The national Tobacco Control Cell (TCC) regularly submits its annual report on the tobacco control situation in compliance with article 21 of the WHO FCTC.
Protect people from tobacco smoke
The Prohibition of Smoking in Enclosed Places and Protection of Nonsmokers Health Ordinance, 2002 regulates smoke free spaces in Pakistan. Smoking and any kind of tobacco use is completely prohibited in public places and public transport in Pakistan. The WHO report of MPOWER compliance gives a quite low score of 3 on a scale of 0–10 for compliance with smoke free environments, highlighting lack of enforcement. Recent GATS also validate the findings [Table 1]. The national TCC found that there were almost 80% of public places where people were found smoking and in almost half of such places (43%) even the staff were found to be smoking. Despite being a commonly violated law, very few cases have been filed so far under this ordinance.
Offer help to quit
This is the most ignored area for tobacco demand reduction in Pakistan. Recent GATS findings show that almost 25% smokers and 21.1% smokeless tobacco users had made a quit attempt during last year but 97.4% could not quit successfully. Currently, there is no policy or program at national or provincial level in Pakistan for supporting people to quit. Physicians provide quitting advice on an ad hoc basis. Nicotine replacement therapy is legally available in Pakistan but is expensive and is not on the national essential drugs list. Another issue is lack of formal training of health providers on smoking cessation. Most physicians feel they have adequate knowledge regarding smoking cessation but lack the skills required to implement tobacco cessation treatment strategies., Pakistani smokers also feel lack of availability of trained health professionals in this regard. There is urgent need to start scientifically valid and culturally appropriate continuous education programs for all cadres of health providers.
Warn about the dangers of tobacco
Despite conclusive evidence on the dangers of tobacco, very few tobacco users actually understand and grasp its health risks. FCTC and MPOWER demand governments to act on warning people about dangers of tobacco use using both anti-tobacco mass media campaigns and displaying warnings on tobacco packages. However, a recent national survey shows that less than one third of Pakistanis are exposed to anti-smoking mass media campaigns. The laws governing warnings on tobacco packages are in place but are limited to cigarettes only, ignoring health of 10 million people who use smokeless tobacco products and 3.7 million water pipe users [Table 1]. Pakistan introduced a law on increasing the size of pictorial health warning to 85% of a cigarette pack size (SRO 22(KE)/2015), but it was never been implemented and delayed again and again due to influence of tobacco industry. Finally when implemented the size of the health warnings was just 60% of a cigarette pack size. This policy compromise highlights the power of industry and under the table settlements.
Enforce bans on tobacco advertising, promotion and sponsorship
Pakistan completely prohibits tobacco advertisement, promotion or sponsorship (TAPS) on any media through the SROs issued by a committee formed to issue guidelines for tobacco advertisement [Table 1]. However, this was awarded a score of 5 out of 10 according to the MPOWER 2019 report, and the recent GATS also validate the poor law enforcement in this regard., A civil society organization, the Network for Consumer Protection, has highlighted the massive volumes of point of sale advertisements and promotions including price discounts in Pakistan. There is lack of data about the extent of incidental advertisement of tobacco products in Pakistan. Public legal procedures are not clear on how to report or initiate complaints against such violations and against whom.
Raise taxes on tobacco
Increasing the price of tobacco through higher taxes is recognized as the single most effective way to decrease consumption. However, Pakistan is among those countries where tobacco products are the cheapest in the world. Pakistan does not tax smokeless tobacco products such as snus, betel quid, and khaini and has a complex tax structure for cigarettes, thus keeping them always affordable to all income groups. To add to the adversity of this situation, even cheaper illicit cigarettes are commonly available. The Government of Pakistan needs to seriously act on this component of MPOWER to reduce tobacco consumption in the country.
| Challenges and Opportunities|| |
Pakistan faces multiple challenges in complying with the MPOWER package of interventions. There are not only gaps in existing policies but a serious lack of implementation of laws where they exist. The country's political economy also poses a challenge for tobacco control in current situation.
Gaps in existing policies
Although Pakistan has adopted several laws for controlling tobacco use and harms in the country, but there are some issues in the existing policies. Pakistani laws mainly focus on manufactured cigarettes while there are over 10 million individuals in the country who use tobacco products other than cigarettes. The most effective tobacco control intervention, raising taxes, applies only to the manufactured cigarettes in Pakistan. Likewise the pictorial and textual warning provisions are limited to manufactured cigarettes only. Pakistani laws are silent on “offering help to quit tobacco use.” There is lack of national policy statement and hence commitment in this regard.
The main challenge in complying with the MPOWER provisions in Pakistan is the limited implementation of existing laws. Pakistan has successfully enacted laws for three of the six MPOWER package of interventions, namely “P,” “W” and “E.” However existing data shows suboptimal level of law implementation and widely prevalent violations as if the laws don't exist. This is not something special for tobacco control laws in the country, Pakistan has an overall culture of limited implementation.,, The commonly cited reasons for this are lack of appropriate funding and workforce to facilitate and monitor implementation. Another reason is lack of clear authority and responsibility for law implementation, multiple departments and actors are involved in enforcing smoking bans and ban on TAPS, but the procedures are not very clear. There are multiple bodies who have authority to implement law but authority is not paired with responsibility or accountability. In absence of such combination, bureaucratic systems may not perform well. There is a need to clarify all laws and establish clear mechanisms on their implementation. Modern technologies, including mobile phone based tools can be utilized for effective implementation. The national TCC monitors law enforcement, but monitoring is not the end per se, there is need to take appropriate actions as a result of information gathered through monitoring.
Political economy of tobacco
Pakistan is among the top 10 tobacco growing countries in the world and its direct contribution to country's economy in terms of tax revenues, employment and exports cannot be ignored. Pakistan's ministry of commerce is actively working to promote tobacco growth and business through its Tobacco Board and recognize it as one of the main sources of national income. The ministry of finance on the other hand is relying on tobacco related revenues, tobacco industry being one of the top five contributors to national exchequer. In contrast to these two ministries, ministry of health aims to curb tobacco use in the country by enforcing FCTC provisions. This inherent conflict of interest between government departments poses a major challenge for effective tobacco control in the country. Tobacco industry utilizes this gap to directly influence policy decisions.
The analysis of MPOWER compliance status in Pakistan indicates that opportunities exist to enhance the implementation of these best practices to control tobacco use in the country. Pakistan can make use of its international commitments for tobacco control, its political will, increasingly used social media, active judiciary and civil society to advance its progress towards implementing MPOWER measures.
International law and collaborations
Pakistan is a party of to the WHO FCTC and is legally committed to take actions to protect its current and future generations from tobacco harms. Many governments have been held accountable before public and in courts by civil society for not taking appropriate actions against their FCTC commitments., Civil society can play an active role in this regard. International donor and other organizations have a strong network in Pakistan; Bloomberg philanthropies is currently supporting the national tobacco control cell, Campaign for Tobacco Free Kids, Coalition for Tobacco Control and other civil society organizations are playing strong role in tobacco control advocacy. The potential of these organizations can be further utilized to help fight NCDs and tobacco.
New political environment
There is new focus on the Nation's health with current government and notable public health proponents; such as Dr. Sania Nishtar, who had been nominated for the Head of the WHO, the current health advisor Dr. Zafar Mirza who has served as Director Health System Development at the WHO Regional Office in Cairo, and the president of the country being a dentist; in key positions in the government.
Utilizing the potential of judiciary
A review of recent history of Pakistan provides numerous examples when the judiciary has played a significant role in highlighting issues of public health and welfare. The most recent examples are the issue of water insecurity for future generations resulting in judiciary initiated program for building dams in the country and restoration of green Karachi by taking actions against structural encroachments. A sensitization of judiciary about tobacco harms can also spur tobacco control efforts and law implementation status in the country.
Social media potential
Recently social media has been extensively used by policy actors including the head of State and other policy makers in Pakistan. This makes it possible for activists and advocates to contact these powerful people with information relating to tobacco control. Scientific evidence shows that using social media sites is a successful way to promote tobacco control efforts and offers a low cost advocacy tool. Using social media and online activism offers opportunity to advance MPOWER compliance in Pakistan.
| Conclusion|| |
Pakistan is making progress towards tobacco control but the level of compliance with the WHO recommended best practices as outlined in the MPOWER package is quite sub-optimal. Pakistan faces multiple challenges including gaps in existing policies, poor law enforcement, and a conflicting political economy of the country to take effective policy actions for tobacco control. However, Pakistan's international commitments and collaborations, renowned public health activists in current government, active and independent judiciary, increasing use of social media, and a dynamic civil society offer opportunities to strengthen its efforts for effective policy actions against tobacco use.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
GBD 2015 Tobacco Collaborators. Smoking prevalence and attributable disease burden in 195 countries and territories, 1990-2015: A systematic analysis from the global burden of disease study 2015. Lancet 2017;389:1885-906.
Mamudu HM, Hammond R, Glantz S. Tobacco industry attempts to counter the World Bank report Curbing the Epidemic and obstruct the WHO framework convention on tobacco control. Soc Sci Med 2008;67:1690-9.
Siddiqui S. Govt' s Tax Scheme Backfires as Tobacco Consumption Increases in Pakistan; 2017.
Ross H, Islam ZU, Aftab S, Janjua J. Study to assess the volume of illicit cigarette brands in Pakistan. Islamab; 2018.
Saeed I, Masud H, Pervaiz F, Azam N, Niazi ZK, Huma ZE, et al
. Preparedness of general healthcare practitioners in 'tobacco cessation counseling/treatment' in twin cities: A cross-sectional study. Pak Armed Forces Med J 2019;69:200-4.
Naeem M, Irfan M, Mawani M, Waheed Z, Haque A, Zubairi AB, et al
. Tobacco cessation treatment: knowledge, attitude and practices of physician in Karachi, Pakistan: A cross sectional study. Heal Med Nurs 2016;27:90-7.
14Shaheen K, Oyebode O, Masud H. Experiences of young smokers in quitting smoking in twin cities of Pakistan: A phenomenological study. BMC Public Health 2018;18:466.
Nishtar S. Choked pipes-reforming Pakistan's mixed health system. J Pak Med Assoc 2010;60:252-3.
Israr SM, Islam A. Good governance and sustainability: A case study from Pakistan. Int J Health Plann Manage 2006;21:313-25.
Nishtar S, Boerma T, Amjad S, Alam AY, Khalid F, Ul Haq I, et al
. Pakistan's health system: Performance and prospects after the 18th
Constitutional Amendment. Lancet 2013;381:2193-206.
TCC. Tobacco Control Cell, Pakistan; 2017. Available from: http://tcc.gov.pk/.
[Last accessed on 2018 Jan 12].
Liberman J. The power of the WHO FCTC: Understanding its legal status and weight. In: Mitchell AD, editor. The Global Tobacco Epidemic and the Law. Cheltenham: Edward Elgar Publishing Limited; 2014. p. 48-63.