Text of my ‘When Worlds Collide’ column published in Ceylon Today newspaper on 31 May 2014
Tobacco control presents formidable policy dilemmas. It isn’t a simple or simplistic battle between ‘good’ and ‘evil’ as anti-tobacco activists would make us believe.
There is no doubt that tobacco kills many smokers — and some non-smokers, too. It was in January 1964 that the US Surgeon General issued the first report of the Advisory Committee on Smoking and Health. Based on over 7,000 papers relating to smoking and disease in biomedical literature, it concluded that cigarette smoking was a cause of lung cancer and laryngeal cancer in men, a probable cause of lung cancer in women, and the most important cause of chronic bronchitis.
During the half century since, much more evidence has piled up, yet tobacco remains a legitimate trade. Starting, continuing or quitting smoking is a personal lifestyle choice which, at least in democracies, governments can’t legislate.
However, as the cost of treating tobacco-caused ill health burdens public healthcare systems, there is a need to control and contain consumption. Tobacco use is now the single most preventable cause of death globally, responsible for 10% of all adult deaths.
“Nearly 6 million people die from tobacco-related illness each year, of which more than 600 000 are non-smokers dying from breathing second-hand smoke,” says the World Health Organisation (WHO). “Unless we act, the epidemic will kill more than 8 million people every year by 2030. More than 80% of these preventable deaths will be among people living in low-and middle-income countries.”
On 31 May every year, WHO leads the observance of World No Tobacco Day, which highlights the health risks associated with tobacco use and focuses on effective policies to reduce tobacco consumption.
Tobacco in Lanka
Non-Communicable Diseases (NCDs) have become the leading cause of illness and death in Sri Lanka, with tobacco use recognized as a key causal factor. In 2009, Sri Lanka’s Ministry of Health estimated that tobacco-related illnesses were responsible for about 20,000 deaths (averaging 57 per day). This is set to increase in the coming years.
An official report, titled Brief Profile on Tobacco Control in Sri Lanka(2009), said 39% men and 2.6% women in Sri Lanka smoked tobacco. Besides cigarettes, other products on the local market are cigars, low-cost and less refined beedis, and betel quid with tobacco leaves.
Sri Lanka signed and ratified the Framework Convention on Tobacco Control (FCTC) in 2003. The National Authority on Tobacco and Alcohol (NATA) was set up through an Act of Parliament in 2006.
Since then, regulations have highly restricted smoking in public places. Tobacco advertising, promotions and sponsorships are prohibited, as are cigarette vending machines. Written health warnings have been mandatory for years.
In recent months, Parliament passed new regulations requiring cigarette packs to contain pictorial health warnings covering 80% of total area. Ceylon Tobacco Company, the country’s monopolist cigarette maker and distributor (mostly owned by British American Tobacco, BAT) challenged this at the Court of Appeal. In a recent ruling, the court limited the pictorial warning to 50-60% of the printable area on the pack.
While the Minister has accepted the ruling (at least for now), activists want to continue fighting for 80%. Key opposition political parties have endorsed this in media comments.
Sri Lanka Medical Association (SLMA), the apex professional body of medical professionals in the country, says it “strongly supports” 80% of pictorial warnings “purely on technical grounds”.
SLMA recently responded to a newspaper editorial (The Sunday Times, 18 May 2014) that asked why the health authorities were focusing on tobacco control without tackling other threats like narcotic drugs, infectious diseases, food safety and (health effects of) pollution.
Dr. Palitha Abeykoon, President of SLMA, and Prof Narada Warnasuriya
chairman of its Expert Committee on Tobacco and Alcohol, argued that “harm from tobacco single-handedly dwarfs all those listed, even if the deaths and disabilities of all those are put together”.
Such single-minded resolve is certainly admirable, but anti-tobacco campaigning in Sri Lanka needs to evolve beyond number games and multinational-bashing.
Activists need mass support to succeed in their policy advocacy as well as public awareness efforts. But to accomplish lasting change, they need to employ more than just populist rhetoric. Taking the moral high ground isn’t enough: they must marshal evidence, study markets and mindsets, strategize, and engage current and potential users of tobacco.
In fact, success will depend critically on good public communication. Being legally mandated to use 50 – 60% of space on a cigarette pack is still a significant opportunity. But that space needs to be used in best possible manner.
Knowing your audience is a first principle in communication. An independent analysis by Amba research and the Colombo Stock Exchange (Oct 2013) notes how most (roughly 95%) of cigarettes are sold in Sri Lanka as loose sticks. If this is indeed the case, most cigarette buyers among us will never get to see 80% (or 50-60%) pictorial warnings! (www.cse.lk/cmt/upload_report_file/460_1384255423645.pdf)
A helpful starting point to understand the mindset and behaviour of Lankan smokers is regular surveys by the Alcohol and Drug Information Centre (ADIC), an advocacy group. Since 1998, ADIC has conducted a public survey twice a year to determine trends in alcohol and tobacco consumption among males above 14 years. (Full reports: http://www.adicsrilanka.org/publication/)
The latest, in July 2013, covered 2,465 boys and men in 10 districts across the island, and from all walks of life. It probed current tobacco users as well as those who have used it at some point in life and those who never have.
It found that 32.5% of the sample currently smoked or chewed tobacco. The highest numbers (36.7%) were among those aged 40 and above while 26.9% of those between 15 and 24 admitted to smoking.
Seven out of 10 current tobacco users do so everyday. Two thirds of daily smokers claimed they used less than five cigarettes a day; only a small percentage (3.9%) admitted to smoking more than 20 a day.
Almost a third (32.7%) of current tobacco users had ‘no obvious reason’ for smoking while nearly as many (31.4%) attributed it to ‘habit’. Other reasons included ‘fun’ (19.3%), ‘to socialize with friends’ (14%) and to ‘forget problems’ (3.4%). Only 1.1% admitted peer pressure, but then it is less likely to be openly acknowledged.
Among current users, 60% have tried to quit the habit at least once – just over half of them because of its potential health hazards.
We shouldn’t read too much into such surveys. But findings in recent years show a gradual decrease in cigarette smoking. This is consistent with global trends, but it still remains a major public health issue everywhere.
Smokers are a defiant lot. Many already know of multiple health hazards of their habit/addiction. They have seen a steady shrinking of public spaces for lighting up. Inside private confines, they are determined to hold out. They are not going to cave in to a nanny state or pious arguments.
Getting inside the smokers’ mind is essential for engaging them. This is where our medical and public health professionals need to work with sociologists, psychologists and communication specialists – including (rare) conscientious advertising professionals.
Anti-tobacco messaging cannot succeed on the (proven) health hazards alone. The image of individuality and lifestyle choice carefully projected by the tobacco industry must be countered through rational arguments and sincere engagement. That takes much time and effort – and not everyone will be won over.
Yes, clever slogans and stunning visuals do help. (My favourite: Tobacco companies kill their best customers!). But don’t judge or condemn smokers — which will only strengthen their resolve.
[Personal note: I have never smoked, and as an asthmatic, react badly to secondhand smoke. At the same time, I don’t accept conspiracy theories on tobacco peddling or pious arguments against tobacco users.]