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University of York researchers found that combustible cigarettes are not the prevalent method of tobacco consumption in Southeast Asia region countries.
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Figure 1: Percentage of current smokeless tobacco users among adults in Southeast Asia region.
Source: K Siddiqi, S Husain, A Vidyasagaran, A Readshaw, MP Mishu, A. Sheikh; Global burden of disease due to smokeless tobacco consumption in adults: an updated analysis of data from 127 countries; BMC Med, 18 (2020).
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What holds true in high-income countries may not necessarily apply to low- to medium- income countries when it comes to tobacco use. Thus, a one-size-fits-all approach to tobacco control should not be adopted. Photo credit: freepik
Findings from a new report by University of York researchers emphasized what should have been obvious long before this – tobacco control policies, particularly in low– to middle–income countries, should address local needs rather than be based on presumptions from high-income countries.
This particular report, titled Common assumptions in tobacco control that may not hold true for Southeast Asia and published in The Lancet Regional Health - Southeast Asia, points out that common assumptions about tobacco control may not necessarily hold true for Southeast Asia and thus can misdirect policy and implementation. This very valid point may be but a blip on the radar for regulators and public health officials in many countries who chose the easier – if less beneficial to their people – path of following the World Health Organization’s (WHO) anti-tobacco creed when developing their tobacco control measures, but it really should not be disregarded.
According to the WHO Report on the Global Tobacco Epidemic 2021, out of the world’s 1.3 billion tobacco users, more than 400 million live in the 11 WHO Southeast Asia region (SEAR) countries (Bangladesh, Bhutan, North Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste.) SEAR has the highest prevalence of tobacco use (27.9% of which 46% are men and 9.7% are women) and is also an important tobacco growing hub, with India and Indonesia being among the top five producers.
According to researchers Kamran Siddiqi, Monica Arora, and Prakash C. Gupta, tobacco control progress in SEAR countries is slow and many policies are not well-developed. They posit that some common assumptions about tobacco use and its control are a key contributing factor for this, as these assumptions may be inaccurate for SEAR, yet these same assumptions remain so firmly rooted in tobacco-related research and policy standards that they mislead policy direction.
Siddiqi et al’s examples of some of these common assumptions start with the interchangeable use of the terms “smoking” and “tobacco” in scientific literature, campaigns, legislature, policies, and services. As Siddiqi explains, “The use of the term ‘smoking’ in scientific literature, policies, and campaigns instead of tobacco is problematic, because in the Southeast Asian region smokeless tobacco is more common than smoking, and as a result policies are not addressing the drivers for its use and how it is produced and sold.”
The researchers say smokeless tobacco, such as snus, is not a harm reduction product in SEAR, unlike in high-income countries such as Sweden and the US where smoking is the most prevalent form of tobacco use and snus is advocated as a reduced-risk alternative to combustible cigarettes. Compared to the low-cost smokeless tobacco products used in SEAR, snus poses reduced risk of disease.
On the other hand, SEAR nations, where 85% of the world’s smokeless tobacco users live, have substantially greater relative risks and population attributable fractions. Therefore, Siddiqi et al argue that promoting smokeless tobacco products as harm reduction tools in SEAR countries runs the danger of undermining ongoing tobacco control initiatives in those countries, where smokeless tobacco use is far more common and related health risks are much higher than in Sweden and the US. Furthermore, the researchers point out, most reports on the health effects of tobacco up until recently were largely based on studies from high-income studies and usually did not highlight what the researchers call tobacco-induced conditions that are relatively uncommon in high-income countries, such as tuberculosis. Instead, the reports tend to cite chronic obstructive pulmonary disease as a common tobacco induced condition without qualifications. Also, lung cancer is normally assumed to be the most common cancer caused by tobacco use. While this is true for countries where smoking is the prevalent form of tobacco use, in Southeast Asian countries, oral cancer is the most common tobacco-related cancer, largely due to the fact that smokeless tobacco is the prevalent form of tobacco used in this region.
In their report, Siddiqi et al concluded that tobacco control in SEAR countries is complicated because of the many ways tobacco is produced, promoted, and sold. The distinct demographic, historical, and sociocultural context of SEAR countries shapes tobacco products’ use and exposure patterns. As such, this particular situation requires contextualized solutions from WHO FCTC as well as outside-the-box solutions to be devised and implemented.
While this conclusion is based on SEAR countries, this conceptual principle could and should be applied to other countries as well, particularly countries in the low- and middle-income bracket. Myopic, one-size-fits-all prescriptions and actions cannot be the answer. Government technocrats should learn that obsequiously following FCTC prescriptions like gospel more often than not leads them astray, forces them to abandon their unrealistic targets, and results in unintended consequences galore.
But then again, one should never underestimate the capacity of activist do-gooders to mess things up in the name of our collective health and wellbeing.