Addressing Pakistan's Smoking Crisis

When one is grappled with the question of ending smoking in Pakistan, one is overwhelmed by the enormity of the challenge. How can a country with more than 31 million tobacco users achieve the target of a smoke-free country? A tall order, indeed. More than half of the tobacco users - 17.3 million - are smokers.

Other indicators are equally depressing. Two of every five smokers start smoking before the age of ten years. With no or little smoking cessation services available, only less than 3% of smokers successfully quit in a year. Tobacco use is associated with more than 160,000 deaths every year in Pakistan. The total estimated costs attributable to all smoking-related diseases and deaths are 1.6% of GDP annually.

Considering these figures, achieving the target of becoming a smoke-free country seems an uphill task. A country is considered smoke-free when the smoking prevalence is below 5%. On the other hand, several countries have been taking measures and successfully marching towards becoming smoke-free. It is important to note that countries are employing all tools, including reduced-risk products, to become smoke-free.

A report - Tale of Two Nations - comparing how Pakistan and Sweden are faring in the fight against smoking makes clear that there is a need for bold measures to reduce combustible smoking. Dr. Delon Human, a specialist family physician and global health advocate, is the author of the report. He has acted as an adviser to three WHO Directors-General and to the UN Secretary-General on global public health strategies.

In Sweden, a bold harm reduction policy, affordable and accessible alternatives, and government support have driven a 46% reduction in smoking since 2015. Sweden is well on its way to achieving smoke-free status. However, in Pakistan, a smoking rate of 12.4%, with only an 18% reduction over the past decade. Smokers have few alternatives, and harm reduction remains absent from the conversation.

It will be instructive to compare the journeys of Pakistan and Sweden. Currently, the smoking rate (as a percentage of the population) in Sweden is 5.3% compared to Pakistan's 12.4%.

Sweden has a formal harm reduction policy. Pakistan on the other hand has no formal harm reduction policy. This is even though Pakistan has an evolving and ever-growing market of reduced-risk tobacco products. However, Pakistan is still not recognizing the role the reduced-risk tobacco products can play in reducing the smoking prevalence.

Lower-risk products are widely available in Sweden. But in Pakistan, the lower-risk products are expensive. The clientage of the lower-risk products, including electronic cigarettes, is upper middle class and rich. Similarly, Sweden has lower taxes on reduced-risk tobacco products. That is not the case in Pakistan.

It is quite strange that people are using the reduced products in Pakistan but in a policy vacuum. There are calls to regulate the use of reduced-risk tobacco products, but nothing concrete has been done yet. It is critical to note that the government in Sweden actively promotes tobacco harm reduction.

Sweden is reaping the benefits of its bold policy. Despite widespread awareness of the harms caused by combustible cigarettes, almost one in every four men in Pakistan is a smoker. Although half of all Swedish men smoked a few decades ago, Sweden's male smoking rate (4.9%) is now less than one-quarter of Pakistan's, and it continues to fall.

Both countries have a history of using oral stimulants. Swedes have traditionally used snus, which public health policy recognized as far less risky than smoking and promoted as a safer smoke-free alternative. In Pakistan, lawmakers have appeared reluctant to embrace oral nicotine pouches and other smoke-free alternatives despite their lower health risks. This means most people continue chewing toxic products such as 'naswar' (a mixture of tobacco, ash and slaked lime) and 'paan' (a betel quid consisting of areca nut and tobacco).

Rather than banning or excessively restricting nicotine products, Sweden embraced safer substitutes. The transition began with traditional snus and later expanded to include vaping in 2015 and nicotine pouches in 2018. By ensuring these alternatives are accessible, affordable and socially acceptable, Sweden has successfully reduced its smoking rate by 54% since 2012.

Sweden's approach has centered on making safer nicotine alternatives both accessible and affordable for adult smokers - a strategy Pakistan has yet to embrace. Currently, Pakistan's tobacco control framework remains firmly focused on restricting cigarette demand, with little emphasis on harm reduction. Pakistan should consider adopting Sweden’s approach of promoting safer alternatives while maintaining existing tobacco control measures. Additionally, Pakistan needs to establish and enforce minimum-age restrictions on all nicotine products, like Sweden, while ensuring adult smokers have access to safer alternatives.

Last but not least, if Pakistan has drastically improved smoking cessation services, Pakistan can become a smoke-free country in the next ten years.