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|Year : 2012 | Volume
| Issue : 4 | Page : 373--378
MPOWER and the Framework Convention on Tobacco Control implementation in the South-East Asia region
World Health Organization, Regional Office for South-East Asia, New Delhi, India
P K Singh
World Health Organization, Regional Office for South-East Asia, New Delhi
The 11 member states of WHO«SQ»s South-East Asia Region share common factors of high prevalence of tobacco use, practice of several forms of tobacco use, increasing prevalence of tobacco use among the youth and women, link of tobacco use with poverty, and influence of tobacco advertisements in propagating the use of tobacco, especially among young girls and women. The effects of tobacco use are many-fold, leading to high morbidity and mortality rates as well as loss of gross domestic product (GDP) to respective countries. The WHO Regional Office for South-East Asia has been actively involved in curbing this menace essentially by way of assisting member states in implementing the WHO Framework Convention on Tobacco Control (FCTC). This paper gives an overview of these activities and discusses the opportunities and challenges in implementing the FCTC and possible practical solutions.
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Singh P K. MPOWER and the Framework Convention on Tobacco Control implementation in the South-East Asia region.Indian J Cancer 2012;49:373-378
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Singh P K. MPOWER and the Framework Convention on Tobacco Control implementation in the South-East Asia region. Indian J Cancer [serial online] 2012 [cited 2020 Dec 2 ];49:373-378
Available from: https://www.indianjcancer.com/text.asp?2012/49/4/373/107738
Tobacco use is a serious public health concern in the South-East Asia Region, where the high-risk use of smoking and smokeless forms of tobacco is widely prevalent. This Region, with 11 member states, has nearly 5% of the global land area, almost a quarter of the global population, over one-quarter of all smokers in the world, and about 90% of the global smokeless tobacco users. The Region has nearly 250 million smokers and almost the same number of smokeless tobacco users. However, the rising trend of tobacco use among young girls and women is of real concern to the member states.
Globally tobacco use kills 5.4 million people annually and causes another 600,000 deaths every year due to exposure to second-hand smoke (SHS).  Three-quarters of these deaths take place in the developing world.
The South-East Asia Region has some of the highest tobacco consuming countries in the world. India occupies the second position and Bangladesh ranks eighth among the world's ten highest tobacco-consuming countries.  In this Region, nearly half of all adult males and two in every five adult females use some or the other form of tobacco. India and Bangladesh have the second and seventh highest number of male smokers in the world, respectively.  Among students aged 13 - 15 years, tobacco use prevalence among boys is higher than among girls. The prevalence of smokeless tobacco use among young girls and women in the Region is increasing largely due to aggressive female-oriented marketing tactics adopted by the tobacco industry.
Consequent to the high prevalence of tobacco use, there is significant tobacco-related morbidity and mortality in the Region. About 1.2 million deaths occur in the Region every year. Smoking was estimated to have caused around 930,000  adult deaths in India alone in 2010; women who smoke in India die an average of 8 years earlier than their non-smoking peers. The ill-effects of tobacco use in women are also of special concern since tobacco use during pregnancy and the post-partum period ,, leads to several complications. Considering the fact that smoking decreases the body's immune defenses and increases susceptibility to opportunistic infections, a major health concern that is inextricably linked to tobacco use is the rising incidence of tuberculosis among smokers in the Region.
Furthermore confounding the problem is the fact that tobacco use and poverty are closely linked. The use of tobacco is high among the poorer sections of the population. Member states of the Region have demonstrated that tobacco users from low-income families spend up to 40% of their income on smoking  at the cost of their basic needs which, in turn, thrusts them deeper into a vicious cycle of poverty. The economic cost of tobacco-related deaths imposes an added burden on countries in the Region, where four out of five tobacco deaths will occur by 2030 and half of all such deaths are likely to occur during the prime productive years. Consequently, the net economic effect of tobacco will thus only worsen the situation of poverty.
Findings of the Global Adult Tobacco Surveys (GATS) and the Global Youth Tobacco Survey (GYTS) point to a high prevalence of smokeless tobacco use among women and girls in the Region. The tobacco industry's marketing strategies and tactics are influencing these young girls and women. More often than not, women bear the double burden of tobacco use, particularly among those in the disadvantaged groups where they use smokeless tobacco and, at the same time, are exposed to SHS of their generally one-room dwellings since the majority of men smoke at home. In addition, those young girls and women engaged in cultivation and manufacturing of tobacco not only endanger their own lives by getting addicted to tobacco and by suffering from other hazards, they also often become victims of labor exploitation.
To combat this menace, WHO-SEARO is actively implementing the FCTC in South-East Asia by country categories. It takes stock of the major progress made and challenges faced in the last few years while implementing tobacco control measures in member states, all of whom have reporting mechanisms related to the FCTC in place. This paper gives an overview of these activities, the problems, and the possible way forward.
Magnitude of the tobacco problem
Prevalence of tobacco use in member states
Smoking among men is high in the Region and women usually take to chewing tobacco. The prevalence across countries varies significantly. Smoking among adult men ranges from 24.3% in India to 67.4% in Indonesia and among adult women it ranges from 0.4% in Sri Lanka to 15% in Nepal. The low prevalence of smoking among women is because smoking by women is not acceptable in most communities in the Region. In contrast to smoking, the use of smokeless tobacco is quite popular among women. The prevalence of smokeless tobacco use among men varies from 1.1% in Thailand to 51.4% in Myanmar, while for women it ranges from 1.9% in Timor-Leste to 27.9% in Bangladesh. 
Overall tobacco use among males is high compared with their female counterparts in all member states of the Region. However, the trend of tobacco use among women is gradually increasing because of the aggressively targeted/oriented marketing tactics of the tobacco industry. Findings from the GYTS show that the current use of any form of tobacco among students is either not decreasing or is increasing in member states of the Region. 
Findings from the Global Health Professions Students Survey (GHPSS) reveal that prevalence of tobacco use is high among medical and dental students in member states of the Region. ,,, Most of them want formal training on tobacco cessation, which has not been provided during their professional training.
Tobacco products and patterns of tobacco use
In South-East Asia, tobacco is mainly produced in Bangladesh, India, Indonesia, and Thailand. India and Indonesia are among the ten biggest tobacco leaf producing countries in the world. India is not only the second largest producer of tobacco leaf but also the third biggest consumer of tobacco in the world. India, Indonesia, and Bangladesh are among the top ten tobacco consumers in the world. 
Various types of smoked and smokeless tobacco products are used in the Region. Among smoked tobacco products, low-cost indigenous tobacco products such as bidis (Bangladesh, India, Nepal, and Sri Lanka), cheroots (Myanmar), and roll-your-own cigarettes (Thailand) are smoked in the Region, especially among the poorer sections of the populations. Clove cigarettes called kreteks are popular in Indonesia. Manufactured cigarettes are the preferred choice of upper class people in the Region. Other forms of smoking products used in the Region include dhumti, chuttas, chilums, hookah, pipes, and cigars.
Smokeless tobacco products are used in different ways such as chewing, sucking, and applying tobacco preparations to the teeth and gums.  The commonly used smokeless form of tobacco in the Region is tobacco with betel quid (known as pan in India, Bangladesh, and Nepal; kwanya in Myanmar; and sirih in Indonesia), which is usually prepared by the users themselves or by vendors in kiosks widely distributed in communities. Another common tobacco chewing product is tobacco and lime mixture (known as khaini or surti in India, and khoinee in Bangladesh), which is either manufactured or prepared by the users themselves. Gutka, a manufactured tobacco mixed with betel nut and other additives, is popular among youth in India and is now seen throughout the Region. Taking advantage of the misconception about tobacco being good for oral health, the tobacco industry is producing tobacco products as dentifrice,  which are most common in India and Bangladesh in different forms such as gul gudhaku, bajjar, tapkir, and lal dantmanjan.
In recent times, the Region has seen an increasing use of smokeless tobacco products among children, youth, and women mainly because of lack of adequate knowledge about the addictive and harmful effects of smokeless tobacco, aggressive marketing by the tobacco industry, and lower prices of and easy accessibility and availability of smokeless tobacco products. 
Who-SEARO measures to combat the problem
The WHO FCTC implementation in the South-East Asia region
The WHO FCTC was developed in response to the globalization of the tobacco epidemic. The Convention provides the principles and context for policy development, planning of interventions, and mobilization of political and financial resources for tobacco control.
In the Region, ten member states have ratified the Convention and are parties to the Convention. Through ratification of the Convention, all parties in the Region have an obligation to implement the International Regulatory Framework to Control Tobacco Use. Currently, member states are at various stages of implementation, and the challenge is to move towards complete implementation of the treaty in all countries.
In order to achieve effective implementation of the Convention, national tobacco control laws have been developed and passed in nine member states and are in progress in others.
WHO-SEARO provided technical support to the countries in developing acts and regulations at national and international level. Effective implementation of the Framework Convention can only be achieved through multisectoral involvement. WHO-SEARO provided a platform for discussion on different issues of tobacco control by organizing a meeting of regional program managers. A regional meeting on trade and several consultations on tax and revenue issues was also organized to bring experts together.
The WHO FCTC articles
Monitoring tobacco use (Articles 20 and 21)
The Region conducted the GYTS in ten member states. It supported the collection of valuable information on the prevalence of tobacco use, knowledge, and attitudes towards tobacco use, role of the media and advertising, access to tobacco products, exposure to SHS, and information on cessation of tobacco use. Member states conducted two rounds of national GYTS. In the Region, nine member countries have conducted Global School Personnel Survey (GSPS) on a national sample. The Global Health Professions Students Survey (GHPSS) was conducted in seven member states of the Region. The GATS in different streams has been conducted in Bangladesh, India, Indonesia, and Thailand. Thailand repeated GATS in 2011. The standard "Tobacco Questions for Surveys"  has been integrated in ongoing surveys in several countries of the Region.
Exposure to SHS smoke (Article 8)
In keeping with Article 8 of the Convention, member states have taken legislative, executive, and administrative measures to protect people from exposure to tobacco smoke in indoor places, public facilities and other indoor public places, and on public transport. Almost all member states in the Region have banned smoking in health-care and educational facilities. Smoking is banned in government facilities and in public transport in several member states. Bhutan, Maldives, and Thailand have completely banned smoking even in restaurants. National law in most member states envisages fines for smoking in public places. WHO has provided information, education, and communication (IEC) materials and also provided advocacy for implementation of such initiatives in collaboration with tobacco control partners.
Health warning labels on tobacco products (Article 11)
Many countries in the Region have implemented specific health warning labels, while a few others are in the process of developing strategies and implementing them. Studies have shown that health warning labels have had a positive impact in some countries.
India has implemented graphic health warnings on all kinds of manufactured tobacco products.Thailand also implemented ten rotating graphic warnings covering 55% of the front and back surface area of cigarette packets, five rotating graphic warnings on cigar packets covering 50%, and two graphic warnings on roll-your-own cigarettes.Bangladesh has provisions for providing six rotating textual-specific health warnings on smoking tobacco products but has implemented the same only on the packets of manufactured cigarettes.Nepal and Sri Lanka have developed regulations on health warnings on tobacco products.The tobacco industry, in order to delay the implementation of health warnings, moved public interest litigations (PILs). In this context, WHO provided technical support as per the request of member states.
Exposure to tobacco advertising, promotion, and sponsorship (Article 13)
All member states (except Indonesia and Timor-Leste) have a policy banning various forms of direct tobacco advertising and promotion on national television, radio, billboards, outdoor advertising, and sponsored events. Some countries have even banned tobacco advertising on international TV/radio and in international magazines/newspapers. The indirect bans such as on free distribution, promotional discounts, and the appearance of tobacco brands in TV are in place in many countries of the Region. Indonesia has limited provisions, but it restricts free distribution of tobacco products. Reducing tobacco imageries in movies in India is one of the best practices. 
Tobacco cessation (Article 14)
Although there is enough indication that most of the users are willing to quit their tobacco habit, currently there are inadequate facilities and training provisions on cessation services in member states. India has 20 tobacco cessation centers and a few community cessation clinics. Thailand has a good network of community health cessation facilities. India and Thailand have developed national tobacco cessation guidelines and have also recently launched national quit lines and telephonic help lines. India is also trying to promote tobacco cessation activities at the district level.
WHO-SEARO has developed the following manuals:
Helping People Quit Tobacco: A Manual for Doctors and DentistsTobacco Cessation: A Manual for Nurses, Health Workers and Other Health ProfessionalsManual on Tobacco Control in SchoolsCommunity Cessation Manual
WHO-SEARO has also supported community cessation in six member states. SEARO provided training at the regional level on tobacco cessation and has also supported national tobacco cessation training in many countries of the Region.
The tobacco control manual for schools has been translated into different languages for use by different member states. Training of teachers has also been supported in some member states.
Sales to and by minors (Article 16)
Although many countries have policies banning sale of tobacco to minors, many young boys and girls can still buy tobacco from a store in the Region. GYTS data reveals that these policies are not well-implemented in member states.
GYTS data revealed that a significant percentage of ever-smokers started smoking at a much younger age. For instance, about two to four out of every ten ever-smokers initiated smoking before the age of 10 years in the Region. Such information calls for an urgent need to incorporate provisions regulating the sale to minors in the laws of all member states as well as ensure effective implementation of enforcement policies.
Taxation on tobacco products
Although countries have increased taxes in every fiscal year, over the last decade, cigarettes have become more affordable in many countries in the Region as inflation rates have not been taken into account while raising taxes. Also, the trend of GDP per capital cost required to buy cigarettes has declined over the years, indicating an increase in actual affordability of cigarettes. Taxation on other tobacco products is far less than on cigarettes and, hence, these are easily affordable to the poorer section of the population. For instance in India, the revenue that is generated from bidis is insignificant compared with cigarettes indicating a wide disparity of tax application between these two smoking items even though ten bidis are smoked for every cigarette consumed. The total percentage of revenue contribution from bidis in 2006-2007 was only 5.7% as opposed to 94.3% for cigarettes. 
To protect the poor from the devastating health and economic impacts of tobacco use, it is important to ensure that tobacco tax on all products is harmonized and meets the standards of the World Bank. Thailand, India, and Nepal have set a good example on this in the Region because part of their tobacco taxation revenue is earmarked for health issues.  An increase in the state-level tax in 16 states of India is one of the unique successes in tobacco control in the Region.
To evaluate the implementation of the Framework Convention in the Region, the data sources used were from the most recent country summary sheets provided by member states; findings from periodic surveys conducted in member states; research conducted on different indicators and assessments by the Central Secretariat of the Conference of Parties (COP). All member states of the Region, except Indonesia, have ratified the Framework Convention during the period 2004 - 2006 and, since then, there have been sustained efforts to accelerate the process of realization of the goals of the Convention.
Significant efforts were made by WHO to curb the tobacco menace and protect the affected populations. It is gratifying to note that ten member states in this Region have ratified the WHO FCTC. WHO-SEARO played a vital leadership role by coordinating and providing support to participate in the Intergovernmental Negotiating Bodies (INB) meeting process of the Convention and further provided technical cooperation and support to Member States in developing guidelines and protocols. Furthermore, WHO provided technical coordination support to countries for drafting and adopting national tobacco control legislatures and for enforcement of the law. WHO-SEARO also advocated with member states for implementation of the Monitor, Protect, Offer, Warn, Enforce, Raise taxes (MPOWER) policy package. Other areas of WHO contribution include sharing health research agenda, setting norms, standards, guidelines, and strategies. Articulating evidence-based policy options, making available training workshop on tobacco cessation, and monitoring and assessing health trends. Besides, the challenges posed by the tobacco industry are also monitored and strategies devised. The regional strategy for tobacco control  and the Regional strategy for utilization of TQS  in 2012 are the most recent examples.
Member states have developed comprehensive tobacco control policies, plans, and strategies and are engaged in implementing them for the best outcomes. Nine member states in the Region have comprehensive national tobacco control laws approved by Parliament (Bangladesh, Bhutan, DPR Korea, India, Maldives, Myanmar, Nepal, Sri Lanka, and Thailand). Indonesia has issued a Presidential Decree and the Law of the Republic of Indonesia Number 36 enacted in 2009 has provisions for tobacco control. The Health Bill in Indonesia considers tobacco as an addictive substance. Legislations of most countries have provisions covering smoke-free places, a ban on tobacco advertising, promotion and sponsorship, and a ban on tobacco sales to minors. In conformity with the resolutions of the Regional Committee (SEA/RC61/R4), all member states in the Region have adopted the MPOWER policy package as an operational tool to implement tobacco control effectively.
Achieving comprehensive tobacco control in the Region calls for addressing some challenges. These range from uniform taxation on all types of tobacco products to making all public places 100% smoke-free and from combating illicit trade in tobacco products to addressing public health interventions and education, which covers all segments of people and all kinds of tobacco products. One of the major challenges that the Region faces is tackling tobacco advertising. A large proportion of the population, particularly young boys and girls, face increased exposure to tobacco advertising and promotion campaigns. The tobacco industry uses tactical and innovative ways to reach its tobacco products to all sections of its targets, including youth and women. Multisectoral action is needed to protect people's health in this Region.
Despite implementing various bans, over one in five young girls and boys are exposed to tobacco advertising on billboards and in print media. One in ten boys and girls have been offered free samples of cigarettes at some point of time and possessed an object (e.g., T-shirts, bags) with a cigarette brand logo on it. 
It is also crucial for the Region to strengthen the surveillance system and have measures in place to counteract any vested interests of the tobacco industry. Wide dissemination of public health policy, ensuring earmarked funding, seeking the commitment of all sections of the people, and providing appropriate enforcement infrastructure and roadmaps are important in implementing the legal provisions successfully.
The Region must continue to work meaningfully and synergistically in tandem with different stakeholders in tobacco control such as policy-makers, health practitioners, epidemiologists, economists, government officials, civil society, NGOs, the media, and all relevant stakeholders to achieve successful implementation of the provisions of the Convention and to take tobacco control to a higher level of enforcement. The collective and sustained efforts of member states are essential to strengthen and advance tobacco control measures in order to fully achieve the objectives of the Convention in the Region.
One of the main obstacles to tobacco control is interference by the tobacco industry in legislative and policy-making processes through lobbying and partnering with organizations inside and outside of government, as well as asserting and maintaining a direct and indirect influence on policy-makers, political leaders, and researchers. It is, therefore, imperative for the governments of the member states to recognize that there is a fundamental and irreconcilable conflict between the tobacco industry and those of public health policy. Ministries of health must be at the forefront in protecting public policy processes from interference by the tobacco industry.
Ever since the WHO FCTC came into force, countries have made significant progress in the Region toward improving tobacco control measures. It is noteworthy that tobacco control is increasingly gaining importance in the political, economic, and social arenas of the countries. The ratification of the WHO Framework Convention on Tobacco Control by most member states in the Region signifies their unparalleled commitment to develop and enforce effective tobacco control policies. Therefore, in line with the objectives of the WHO FCTC, the countries need to fully implement the treaty to protect people from the devastating health, social, environmental, and economic consequences of tobacco consumption and exposure to tobacco smoke. Member states are urged to place the treaty at the core of their efforts to control the global epidemic of tobacco use and to reduce the burden of tobacco-related diseases and deaths.
It may be said that there are many challenges in combating the tobacco menace, but equally encouraging is the fact that there are several success stories and WHO is confidently looking forward to achieve the objectives of the WHO FCTC.
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