Pakistan: A challenge to quitting smoking

Tobacco was not cultivated in Pakistan when the country gained freedom. It had to be imported to meet local demand. Tobacco manufacturing began on a trial basis in 1948. Prior to 1968, however, the standard of tobacco cultivation was poor, necessitating massive tobacco imports.

To promote the cultivation, production, and export of tobacco and tobacco products, Pakistan Tobacco Board was founded in 1968 as a federal public sector institution. Till today the board is responsible for regulating, controlling, and promoting the export of tobacco and its products along with fixing grading standards. One of its important functions is to “collect statistics on any matter relating to tobacco and tobacco industry.” This is one area where the board and those making calls for tobacco are lacking. Tobacco-related data, both in terms of its production and its use in Pakistan is out of date.

According to available data, globally Pakistan ranked ninth in terms of raw tobacco production in 2016-17, 18th in terms of area cultivated, and 31st in terms of yield per hectare. According to Food and Agriculture Organization statistics, the country’s cigarette output surged by more than 60 billion cigarettes between 2000 and 2016. From 2000 to 2017, the total area of tobacco planted increased by 0.27 percent per year, from 45.6 to 47.7 thousand hectares. Similarly, tobacco production increased from 85.1 to 113.4 thousand tonnes between 2000 and 2017, with a 1.90 percent annual growth rate due to an increase in per ha yield (at 1.64 percent per year) and a 0.27 percent annual increase in crop area. The tobacco industry, directly and indirectly, employs 350,000 people, generates about Rs300 billion in yearly revenue, and employs 1.2 million people.

In 1948, Pakistan was a net importer of tobacco. By 1969, it had become self-sufficient due to the adoption of new tobacco varieties, advanced tobacco cultivation methods, and collaboration between industry, government, and tobacco farmers. According to the Pakistan Institute of Development Economics study, the most effective strategy to minimize tobacco usage is to increase prices by increasing taxes and ensuring that the tax increases are reflected in pricing. Higher costs deter people from starting to smoke cigarettes in general, and young people in particular, and urge existing smokers to stop.

In 2013, Pakistan changed its tobacco excise tax system. For cigarettes, there is currently a two-tiered special excise tax system in effect. The lowest and highest grades of cigarettes cost Rs17.6 and Rs46.50 for each pack of 20 cigarettes, respectively.

However, the tobacco industry’s tax contribution grew to Rs120 billion in 2019, up from Rs92 billion in 2016, since the government eliminated the third tax category in 2019, limiting the tobacco industry’s ability to provide cheaper cigarettes by avoiding taxes.
The tobacco industry’s portion of overall tax revenue increased from 2.15% to 3% in FY17. The government’s aversion to changing tobacco tax policy stems in part from a misunderstanding of the share of health and social expenses that may be attributed to smoking. As a result, its benefit-cost analysis of tax revenue is wrong, putting overall health outcomes in jeopardy.

The entire cost of all smoking-related illnesses and deaths in Pakistan in 2019 was Rs615.07 billion ($3.85 billion), with indirect expenses (morbidity and mortality) accounting for 70% of the total cost. Rural residents bear 61% of the total cost, men 77%, and those aged 35–64 years bear 86% of the burden.

The total tax payment (Rs120 billion in 2019) accounts for roughly 20% of the total cost of smoking-related hazards. The overall direct and indirect costs of smoking-related cancer, cardiovascular disease, and respiratory diseases amount to Rs437.76 billion (the US $2.74 billion), or 3.65 times the tobacco industry’s total taxable income. Direct mortality costs account for 23% of total expenses, whereas indirect mortality costs account for 64%.
The government of Pakistan along with health-related national and international organizations, NGOs, and civil society groups devote a substantial amount of taxpayer money to tobacco-reduction programs. These interventions include increasing tobacco-related lobbying, changing the image of tobacco by forbidding direct and indirect advertising and implementing hard-hitting anti-tobacco public education campaigns, protecting nonsmokers from secondhand smoke, and so on.

Recently, the World Health Organization has recognized the Tobacco Control Cell of Pakistan’s health ministry with a World No Tobacco Day 2021 Award. According to Pakistan’s tobacco control activists, the award was given to Pakistan for its efforts over the last decade, which included significant policy work on tobacco control, implementation of the Tobacco-Smoke Free City model, mandating pictorial health warnings on cigarette packs, and gradually increasing the size of the warning, and so on.

However, this success has been questioned given the fact that the number of tobacco users has reached 29 million, according to Pakistan’s Household Integrated Economic Survey 2018–19. The consumption of tobacco is higher in poor (49 percent) than in rich households (38 percent). Commenting on the reward, daily Dawn said: “Access to smoking products is easy and the availability of the ostensibly banned single cigarettes is especially tempting for students and other young people.”

Smoking remains the largest preventable cause of death in Pakistan. Tobacco is responsible for around 160,100 fatalities in Pakistan each year. Every day, more than 1,200 Pakistani children aged 6 to 15 begin smoking.

According to the Global Adult Tobacco Survey, roughly 24 million individuals (19.1 percent) used tobacco in some form in 2014–15. Tobacco use has increased to 15.6 million (12.4 percent), with 3.7 million using water pipes, hookahs, or shisha and 9.6 million (7.7 percent) using smokeless tobacco. Further, cigarettes can be purchased and smoked at universities, colleges, hospitals, airports, railway stations, and bus stations. It is simple to obtain loose cigarettes.

Smoking cessation still remains a weak link in the tobacco control efforts in 2022. Only in 2017, Pakistan made nicotine replacement therapy (NRT) part of the Essential Drugs List. There is only one smoking cessation clinic working in a public hospital in Islamabad. NRTs are expensive and not easily available in Pakistan.

A dedicated quitline has been introduced but it is not widely advertised. Its performance remains disappointing. The quitline received 2,371 calls from 1 January 2015 to 1 September 2020. Of the 2,371 smokers registered through the quitline, 1,439 were referred to the National Institute of Rehabilitation Medicine (NIRM), which houses a tobacco cessation clinic, and of the 1,439 smokers referred to NIRM, only 73 succeeded in quitting smoking during the last five years. Another 932 callers availed online consultations. Only less than 3% of smokers successfully quit smoking in a year in Pakistan.

It is important to highlight that the Smoking and Protection of Non-Smoker’s Health Ordinance 2002 makes no mention of smoking cessation. The main issue is determining how to reduce the health dangers linked with tobacco usage while simultaneously saving Rs615.07 billion in human lives and intellectual endeavors. The shift in the cigarette business is the answer.

Pakistan ratified WHO FCTCs in 2004. Eighteen years on, the country still lacks a national policy on tobacco control. Additionally, the tobacco control efforts seemed to have stalled in a time warp. A number of countries, including the UK, Japan, and Sweden, are making the concept of harm reduction part of their tobacco control plans and setting targets for completely ending combustible smoking. Pakistan seems to be completely ignoring this aspect.

Overall, Pakistan must take significant measures to reduce its use of combustible tobacco. These include making smoking cessation programs more accessible and affordable, including smokers’ perspectives in tobacco control policies, incorporating NRT into national tobacco control strategies, and sensibly regulating NRT products.