Social movement is an imperative to end tobacco game!

Shobha Shukla, Citizen News Service - CNS
This was made amply clear during a two day workshop on 'Enforcement and Monitoring of Pictorial Health Warning’ held recently in Bali. Organized by International Union Against Tuberculosis and Lung Disease (The Union), in collaboration with School of Public Health, Udayana University, it provided a platform for countries in the South East Asia Region to share their experiences in the field of tobacco control with a view to enhancing capacity for enforcement and monitoring of pictorial health warnings.

Here is a snapshot of what some of the representatives shared with CNS, regarding their countries’ triumphs and challenges in tobacco control.


Whereas increasing tobacco use in youngsters is a concern in most SE Asian countries, it is the lowest in Cambodia. Tobacco use in 13-15 years youth is 6.3% (7.9% in boys and 5% in girls). Only 0.2% youngsters smoke cigarettes, as per GYTS 2010. A much bigger problem is use of tobacco in adults. Even though tobacco consumption in adult men has reduced from 49% in 2005 to 43% in 2011, it still is very high.

In terms of legislation, there were two sub decrees on health warnings in 2008 and a complete ban on TAPS in 2011. In 2013 there was a proclamation to promote voluntary participation for banning smoking in public places, which is likely to be enforced soon. Currently sub decree on 55% PHW is being drafted. Implementation of PHW is a new intervention in Cambodia and requires support from policy makers and public. There is proposal to implement 90% PHW in Cambodia.

Dr Sin Sovann, Deputy Director, National Centre for Health Promotion, Ministry of Health, Cambodia, shared with CNS (Citizen News Service) that during the last 15 years concerted efforts of many stakeholders, in tobacco control have brought about a sea change in people’s behavioural pattern.

“Smoking in Cambodia has had cultural sanction. During a wedding ceremony, the bride must offer a cigarette to the bridegroom and light it for him too, thus showing her respect for him. At the wedding feast that follows, the couple would offer cigarettes to all the guests present. This custom had been a very old one. But thankfully, due to sustained tobacco control interventions it almost disappeared from our society around 2003. This has been a great social change”, said Dr Sovann.

To fight and win the war against Big Tobacco, Sovann called for more harmonization and unity among different tobacco control stakeholders in Cambodia and elsewhere too. Partnerships are very important to face the challenge posed by tobacco industry interference.

“Tobacco companies interfere with the Ministry of Health, whenever some legislation is to be passed and this slows down the process of tobacco control implementation. The proposal for implementing 90% PHW was accepted at lower level, but was rejected at the highest level. So we have to increase our advocacy activities. Also tobacco control must become a priority area for the government,” he said.


Timor Leste ratified FCTC in 2004 and since then some steps have been taken by the government for banning TAPS, and having smoke free areas in some public places—work places and schools. There is a decree to restrict tobacco advertisement on social media, TV, video. Recently, healthcare providers have been trained in tobacco cessation services and start tobacco cessation services are expected to begin soon in selected hospitals and health facilities.

Yet there is a very high usage of smoking and smokeless tobacco in the country. 70% of adult men and 9% of women are smokers. Smokeless tobacco is used by 16% men and 27% women. As per GYTS 2013, smoking tobacco use is 61% in boys and 15% in girls (overall 35%). In 13-15 years old boys tobacco use is 15% and in girls 17%.

Dr Heculano S Dos Santos, Head of NCD and Mental Health department, Ministry of Health, Timor-Leste and regional coordinator for FCTC for Southeast Asia told CNS that, “There is no data on mortality due to tobacco use. But some data from hospitals show that more than 60% mortality is due to NCDs. This can be used as evidence for having stricter measures. Prevalence of TB is also very high in Timor Leste. There are more than 557 TB cases per 100,000 population. Tobacco is responsible for 20% of them. There is need for the TB programme and NCD programme to work together with tobacco control programme”.

Speaking of challenges in tobacco control he said that, “There is high socio-cultural acceptance of tobacco in the country, which is a huge problem. There has to be strong advocacy to make behavioural changes in people. Taxes on tobacco products are low and so they are cheap and easily accessible to people. We have to convince other Ministries, like that of Finance, to increase taxes. Even though tobacco advertisements are banned on our TV channels, there is free access to advertisemnets of tobacco products through TV, radio and social media channels of other SEAR countries that are beamed in Timor. Tobacco industry interference is high and so is cross border illicit trade of cigarettes. We need to enforce strict implementation of current regulations and also endorse (and then implement) the new regulations”.

The new legislation under consideration of the cabinet includes:
(i) ban on smoking in all public places,
(ii) regulation of content of tobacco products, pricing and tobacco taxes,
(iii) having pictorial health warnings (PHW) on tobacco packs,
(iv) ban on sale of tobacco products to and by minors,
(v) ban on tobacco advertisements and sponsorship by tobacoo industry,
(vi) offering tobacco cessation services, and
(vii) defining infraction, fine, monitoring and evaluation. Even though currently there are no users of e-cigarettes, as a foresight, the new regualtions ban import of electronic nicotine devices (ENDS) and waterpipes as well.

“Our new government is now in the process of passing new legislation and as soon as it gets approval we can intensify our tobacco control efforts. The new Prime Minister is a medical doctor and he as well as his cabinet members are cognizant of hazards of tobacco. The President is also very motivated to endorse the new legislation. So political commitment at the moment is very strong. All of them are supporting the new legislation to be approved as soon as possible,” said Santos.


Smoking is socially acceptable in Vietnam, which is one of the top 15 countries by way of smoking prevalence in adults. 47.4% of adult males and 1.4% adult females are smokers. 84% of all the smokers smoke cigarettes and 27% use waterpipes. Every year 40,000 people die due to 3 major tobacco related diseases—lung cancer, COPD and stroke. Thus tobacco is responsible for 21% of deaths in men and 19% deaths in women every year.

Apart from loss of human lives, tobacco also results in high economic loss for the country as 0.22% of its GDP or 4.3% of total health expenditure amounting to USD 77.5 million is spent on covering cost of lung cancer, COPD and ischaemic heart disease, annually.

Le Thi Thanh Huong, from Hanoi School of Public Health, Vietnam informed that Vietnam has a law on tobacco control that includes smoke free areas in public places; comprehensive ban on TAPS, except for philanthrophic purposes; tobacco cessation; PHW occupying 50% area on front and back of the packs; and decrees for different Ministries on how to implement the law. However, implementation is poor, especially in the hospitality sector. As they fear losing their customers, they have designated places for smokers in their establishments, even though as per the law restaurants/ hotels have to be smokefree throughout. Also there is no monitoring system to ensure that all tobacco packs sold are complying with it PHW regulations”.

Huong lamented that, “While smoking in youth is decreasing e-cigarette use is increasing. Trend for smoking sheesha is also on the rise, especially in pubs frequented by the youth. There is tobacco industry interference in every area of tobacco control. In case of PHW, pictures are often dimmed or not clear and PHW is often partly covered with tax sticker. On top of this tobacco control in particular, and health in general, are not on the top priority list of the government. Also, there is lack of human and financial resources. Tobacco industry has to pay 1% of the producers’ price as tax to the government. This fund is divided among 63 provinces of the country for implementing tobacco control activities. We do not have enough people to guide on implementation. Enforcers are also not experienced and trained.” 


Myanmar ratified FCTC in 2004. Chewing tobacco is more prevalent than cigarettes. Tobacco use is socially and culturally accepted. Smokeless tobacco use is more prevalent. In 2010, NCDs were estimated to account for 42% of all deaths.

U Thant Zin, Deputy Director in the Attorney General’s Office, Myanmar said that, “We have the ‘control of smoking and consumption of tobacco products law’, which was enforced in 2007. Current PHW are in Myanmar language in very small font size and only on one side of the package. Now we are trying to issue a notification to include 75% PHW. We have designated smoke free areas like buses, trains, near schools. Tobacco advertisements are banned. Use of e-cigarettes is rare and they are not easily available”.

According to him the main challenges in tobacco control are poor public awareness about the National tobacco control legislation and also weak enforcement of law. There are limited resources for cessation facilities. At the same time there is influence of tobacco industry, and prices and taxes on tobacco products need remain low.

However, there is political commitment from the President, and good collaboration between related Ministries (especially education ministry). Academic institutions, NGOs and media are aslo involved for social mobilization.

Dr Farrukh Qureshi of WHO Indonesia reminded the participants that FCTC is the most widely embraced treaty in the world. It establishes tobacco control as a priority on the public health agenda, providing a political and legal platform for adoption of sound, evidence based tobacco control measures and introduces a mechanism for firm country commitment and accountability. Ratified by 180 Parties covering about 90% of the world’s population, it represents a unified global response to the global tobacco epidemic.

As Farrukh rightly commented tobacco control is a social movement. We need support from lawyers, politicians, doctors, civil society to join forces to unitedly defeat a financially powerful formidable foe—the tobacco industry.

Shobha Shukla, Citizen News Service - CNS24 September 2015