How Sri Lanka and Nepal are stubbing out cigarettes to cut cancer rates

A five-year study looks at how taxes and product labelling made an impact

Taxes on cigarettes were raised in Nepal as part of a bid to reduce the number of smokers. AFP

With the number of cancer cases caused by smoking at an all-time high globally, countries like Nepal and Sri Lanka with significant tobacco consumption were seen in need of policy changes and better control to cut cigarette use.

A five-year project by Cancer Research UK (CRUK) and economic development agency Kivu International, revealed how taxes and product labelling of the dangers of smoking in these countries were found to be effective models.

According to the 2019 project, discussed at the World Cancer Congress in Geneva, many in Sri Lanka were forced to quit smoking completely after taxes on cigarettes increased to 60 per cent in 2020.

It showed how 15 per cent of the adult population smoked or used tobacco in 2015, but by 2020, that number fell to 9 per cent.

The prices - $7 for a packet of 20 cigarettes - earned the Sri Lankan government Rs32 billion as tax income during the same year.

“The programme was targeting what we call last mile smokers and to ensure that the successes we'd made over the years remained,” said Nisha Arunatilake, from the Institute of Policy Studies of Sri Lanka, a think tank developed as a result of the collaboration.

“When we started the programme, there was a lot of pushback from the industry. Further tax increases didn't have an impact on the revenue because at the time Sri Lanka was in an economic crisis.

“But, we are now able to predict how different policy changes would impact revenue and how that would impact prevalence, while also trying to develop how the impacts on lives saved and health costs are reduced.

“One of the challenges was the misinformation being fed by the industry, usually strategically just before elections or budgets, suggesting tax increases would show a sharp rise in smuggling or informal tobacco use. Now we've created evidence-based knowledge that can refute that.”

A similar project is now being looked at in Kenya and Uganda, to reduce cigarette use and the risk of lung cancer, the leading cancer worldwide and responsible for 1.8 million deaths annually.

'Raising the profile of tobacco as a health issue'

“In Nepal, the issue around tobacco was very low down the political agenda,” explained Olivia Stevens, a policy adviser at Kivu International.

“A lot of the work was done building coalitions with NGOs (non-government organisations) and research institutions to raise the profile of tobacco as a health issue." Even when one in five deaths in the country was linked to non-communicable diseases, like cancer and heart diseases.

“A five-year programme with CRUK allowed time for the policy advocacy strategy to develop. There were, definitely, a lot of challenges with industry backlash a big one and I think we saw that very significantly in Nepal, as we had two big increases in tobacco taxation within the early years of the project.”

A 25 per cent rise in tobacco tax in 2022 was the largest for a decade and contributed to a 20 per cent increase in government finances 12 months later.

While smoking rates remained high in Nepal at about 30 per cent, they were beginning to fall.

India records highest smoking rates

The use of tobacco remains a significant public health challenge in India, with the cheapest packet of 20 cigarettes costing around $1.55, compared with just 40 cents in Nepal. The most popular brand, however, sells for around $2.32.

India records some of the region's highest smoking rates at around 253 million tobacco users.

Results from a national demographic health survey published in 2021 showed around 10 per cent of adults in India smoked tobacco, but a further 21 per cent used smokeless tobacco.

More than a million people die from illness related to tobacco use in India each year, around 9.5 per cent of total deaths.

“India has the highest burden of oral cavity cancer cases, that’s over a third of the global burden is in India," said Dr Gauravi Mishra, from the preventative oncology department at the Tata Memorial Hospital in Mumbai.

She studied public transport workers and police in the city to assess tobacco cessation programmes.

Of the 43,650 police in Mumbai surveyed, 35 per cent of men used tobacco, and just 4 per cent of women.

In 2019, the hospital offered screening for oral cancers for police and transport workers across a three-year programme. Workers were offered regular support to encourage them to quit, with urine tested during regular health check-ups to assess progress, workshops and medical support.

There had previously been no tobacco cessation projects available for police in Mumbai before the intervention.

“Working in the police is very stressful,” explained Dr Mishra. “The officers have different dietary and sleep patterns, which exposes them to the risk of several non-communicable diseases, including cancer.

"They are also at high risk of all forms of addiction, including tobacco and alcohol."

It's not just the police force, the time has come to take tobacco control and cessation programme all over India, he added.

Changes in public health policies

The Association of South-East Asian Nations (ASEAN) has been at the forefront of public health changes to reduce the number of smoking-related deaths across Asia, a region with about 600 million daily smokers.

The South-East Asia Tobacco Control Alliance (SEATCA) scorecard provides a numerical score for each country with indices on smoke-free tobacco tax industry interference, tobacco advertising, packaging and labelling, to track progress in accordance with the World Health Organisation policy.

Last year, Thailand had the highest score of 77 per cent, followed by Singapore with 75 per cent.

Points were also awarded for regulation over e-cigarettes, which are banned in Brunei, Cambodia, Lao PDR, Singapore and Thailand.

Ulysses Dorotheo, of the South-East Asia Tobacco Control Alliance (SEATCA), said while 10 countries in the bloc are at different stages of tobacco control, Singapore is leading the way with a national smoking rate of just 9.2 per cent.

“There was a big need for capacity building for tobacco control in the region, and technical knowledge is well advanced now in almost all ASEAN countries with regard to tobacco control,” he said.

“All ASEAN member states have health warnings on their packages, the only region in the world to achieve this so far.”