Prevention & Control of Smokeless Tobacco in the South-East Asia Region

Prevention & Control of Smokeless tobacco in the South-East Asia Region

Dr. Jagdish Kaur Regional Adviser, Tobacco Free Initiative WHO Regional Office for the South-East Asia

Percentage of current tobacco users (Smoking and Smokeless) among adults (Male) in selected Member States of the South- East Asia Region

62.2 Myanmar 43.8 79.8 16.1 Timor-Leste 69.5 70.6 1.5 Indonesia 67 67.4 26.4 Bangladesh 44.7 58 31.3 Nepal 27 Smokeless 48.1 1.1 Smoking Thailand 46.6 47.2 Total 26 Sri Lanka 29.4 45.7 29.6 India 19 42.4 3.9 Maldives 34.7 36 26.5 Bhutan 10.8 33.6 0 10 20 30 40 50 60 70 80 90

Percentage of current tobacco users (smoking and smokeless) among adults (Female) in selected Member States of the South- East Asia Region

24.1 Myanmar 8.4 29.1 26.8 Timor-Leste 9.6 28.9 27.9 Bangladesh 1.5 28.7 12.8 India 2 14.2 4.8 Nepal 10.3 14.1 Smokeless 11 Smoking Bhutan 3.1 13.6 Total 5.2 Thailand 2.6 7.6 5.3 Sri Lanka 5.3 2 Indonesia 2.7 4.5 1.4 Maldives 3.4 4.4

0 5 10 15 20 25 30 35

[Source - Global Adult Tobacco Survey (GATS) and NCD STEPS] [Available from: http://www.searo.who.int/tobacco/data/adult_tobacco_brochure_2015.pdf] [Note: Order of the above countries is taken based on total prevalence of tobacco use] [Note: In Sri Lanka SLT (smokeless tobacco use) for female is not available as numbers of respondent are less to calculate the prevalence] Percentage of current tobacco users (smoking and smokeless) among Youth (Boys) in selected Member States of the South-East Asia Region

7.7 Timor-Leste 61.4 65.5 25 Bhutan 26.3 39 3 Indonesia 35.3 36.2 11 Myanmar 21.1 26.3 19.7 Nepal 11.4 24.6 Smokeless 4.1 Smoking Thailand 20.7 21.8 Total 11.1 India 11.2 19 9.2 Maldives 10.4 15.2 5.9 Bangladesh 4 9.2 4.2 Sri Lanka 3.2 6.7

0 10 20 30 40 50 60 70

[Source - Global Youth Tobacco Survey (GYTS); Bangladesh (2013), Bhutan (2013), Maldives (2011), India (2009), Indonesia (2014), Nepal (2011), Myanmar (2016), Sri-Lanka (2015), Thailand (2015), Timor-Leste (2013)] [Note: Order of the above countries is taken based on total prevalence of tobacco use] Percentage of current tobacco users (smoking and smokeless) among Youth (Girls) in selected Member States of the South-East Asia Region

9.3 Timor-Leste 15.4 23.9 18.9 Bhutan 8.6 23.2 12.9 Nepal 6.5 16.4 6 India 3.7 8.3 1.3 Thailand 7.1 8.1 Smokeless 2.9 Maldives 5 Smoking 6.7 Total 1.1 Indonesia 3.4 4.3 1.5 Myanmar 2.4 3.7 2 Bangladesh 1.1 2.8 0.5 Sri Lanka 0.2 0.7

0 5 10 15 20 25 30

• WHO SEA Region is home to one fourth of world’s population & > 80 % of ST users. • Bangladesh, India, Myanmar and Nepal have a sizable proportion of ST users. • Most ST products contain area nut/betel leaf along with different additives/flavoring agents. (70% in India to 98% in Bangladesh). • High social and cultural acceptance. • Belief that ST is less harmful.

Traditional ST products

ST Policy Initiatives Article 6 - Taxes

• Bhutan has ban on growing, production, manufacturing and sale of tobacco and 100% sales tax and 100% custom duty is applied on tobacco products for personal consumption only. • ST is taxed at low rates compared with cigarettes in many countries, mainly Bangladesh, India, Myanmar and Nepal.

Articles 9&10 – Product Regulation

• Limited of testing facilities • Lack of priority and coordination • India has National Tobacco Testing labs Programme in place Regulating ST in SEA

Country Party to FCTC FS Law for ST ST Ban Bangladesh Yes - - Bhutan Yes - x DPR Korea Yes - x India Yes x x Indonesia No - x Maldives Yes - x Myanmar Yes - - Nepal Yes - - Sri Lanka Yes - - Thailand Yes - x Timor-Leste Yes - - FS: Food Safety, x: law is in place; (-):No specific provision

Article 11-Health Warnings on tobacco product packs 90% 90% 85% 85% 80% 80% 75%

70%

60% 50% 50% 50% 40% 40% 30% 30% 30%

20%

10%

Note: DPRK and Maldives have provision for only text warnings Education & Awareness campaigns • India and Bangladesh are examples of awareness and media campaigns specific to smokeless tobacco, funded by the national governments. • India, Bangladesh & Myanmar have developed material for education and training on smokeless tobacco Article 13 TAPS ban

• India and Bangladesh have ban on tobacco advertising, sponsorship and promotion (TAPS) including smokeless tobacco. • Enforcement is a cause of concern.

Article 14- Cessation

• India launched the mTobacco Cessation programme, using mobile technology for tobacco cessation with the support from the WHO-ITU. • India Quit Line covers smokeless tobacco. • Bhutan and India have national tobacco dependence treatment guidelines which include smokeless tobacco cessation. ST Cession study -SEAR

• To understand the needs and challenges of ST cessation in five countries with high prevalence of ST consumption among adults and youth -Bangladesh, Bhutan, India, Myanmar and Nepal. • Conclusion : The existing health systems are grossly deficient to meet the current demands of ST cessation. Main findings

• Limited number of good practices on ST cessation in the SEAR • Resource crunch • Inadequate training and capacity building on ST cessation • Lack of enabling environments • Absence of multi-stakeholder engagement and partnerships

Article 15 - Illicit trade of tobacco

• Sri Lanka is the only SEA Region Member State which has ratified the Illicit Trade Protocol. Article 16 - Access of tobacco to & by minors • Bangladesh, DPR Korea, India, Indonesia, Maldives, Myanmar and Nepal prohibit sale of all types of tobacco to and by minors (up to 18 years of age). • Sri Lanka has prohibition on the sale of any tobacco product to persons under 21 years of age. • Thailand (2017) - age of prohibition for sale to and by minors is raised to 20 years. • Sales to and by minors (under 17 years) is prohibited in Timor-Leste.

Surveillance

• Flavored ST is not well defined, its assessment in various health surveys is yet to be standardized. • Limited data available on flavored ST use • Non-uniform assessment of ST, especially flavored ST across countries

Research

• Limited research on harmful effects of ST products prevalent in SEAR • Lack of research on ST and betel nut flavored products • Lack of research on addictiveness and toxicity of ST