n 2014, Pakistan made public the results of its Global Adults Tobacco Survey (GATS). The GATS is a global standard for systematically monitoring adult tobacco use (smoking and smokeless) and tracking key tobacco control indicators. It was termed as the “first nationally representative survey planned to collect data on tobacco use among adults as well as their knowledge and attitudes towards tobacco control measures.”

With the technical assistance of the World Health Organisation and the US Centre for Disease Control and Prevention (CDC), the GATS-Pakistan was conducted by the Pakistan Bureau of Statistics (PBS) under the coordination of the Ministry of National Health Services, Regulations and Coordination (NHSRC).

As a result of the first GATS, the authorities learnt that Pakistan had about 23.9 million (19.1 percent) adult users of tobacco. Of those, 15.6 million were smokers and 3.7 million smoked shisha. Smoking was, as it is today, more prevalent among men (31.8 percent) than women (5.8 percent). Tobacco use was higher in rural (21.1 percent) than in urban areas (15.9 percent). Secondhand smoke turned out to be a major issue. Nearly 70 percent of people were exposed to second-hand smoke at the workplace within 30 days of the survey. Almost half of the adults (56.3 million) were exposed to SHS at home at least once a month.

The Ministry of National Health Services, Regulations and Coordination (NHSRC) is planning to conduct a second round of the survey. This is a step in the right direction. The scale of tobacco use seems to have grown since the GATS-I. Some estimates put the number of tobacco users at 31 million; other estimates put the number at 29 million. In February 2023, the government raised the Federal Excise Duty by 153 percent.

Though reports based on anecdotal evidence say that the increase in the prices of cigarettes has forced some of the smokers to quit, it is too early to make such a claim. The presence of illicit and duty-not-paid cigarettes in Pakistan is adding to the confusion regarding tobacco use and the smoking prevalence.

Elsewhere, the world is moving ahead with plans and targets to end combustible smoking by 2040. A number of countries, including New Zealand, are working to have a tobacco-free generation (TFG). Another critical factor in ensuring a smoke-free world is tobacco harm reduction products (THR).

The Ministry of National Health Services, Regulations and Coordination (NHSRC) is planning to conduct another survey. This is a step in the right direction. The scale of tobacco use seems to have grown since the GATS-I. Some estimates put the number of tobacco users at 31 million.

In the last five years, Pakistan has witnessed the use of THR products, mainly e-cigarettes. Though there is a fierce debate regarding the efficacy of THR products in helping adult smokers quit or switch to safer alternatives, these are legally imported and sold in Pakistan. It can be said that the THR products are being used in a regulatory vacuum.

It is essential that the GATS-II should cover the whole spectrum of tobacco use in Pakistan. Apart from gauging the smoking prevalence, it should also look at the use of THR products, especially in the context of the intention to use them. Is it for quitting or switching to a safer alternative or is it merely a fashion statement? Additionally, it should closely examine the users of THR products in order to see if these have helped adult smokers quit or switch to safer alternatives or if they have become dual users.

Ignoring THR products would be like ignoring a piece of the puzzle to solve the riddle of tobacco control.

It is important that Pakistan comes out of the denial mode vis-à-vis the THR products. It serves no purpose but forces smokers to keep smoking combustible cigarettes. Currently, the use of THR products is rising despite the fact that the federal and provincial governments, the WHO and the organisations working on tobacco control refuse to recognise their effectiveness in helping adult smokers. This will not solve the smoking endemic Pakistan is facing.

It is clear from the experiences of developed countries that tobacco control is not about finding a panacea but a collection of measures that help reduce smoking prevalence. Nicotine pouches— SNUS — are part of Sweden’s successful tobacco control policy to achieve the status of a tobacco-free country.

GATS-II provides an opportunity to gauge the scale of the problem of smoking along with the range of solutions available. Besides revisiting the legislation on tobacco control, the role of provincial governments and higher taxes, Pakistan needs to review and debate the role of THR products in reducing smoking prevalence.

The writer heads the Alternative Research Initiative, a research-basedconsultancy working for ending combustible smoking in Pakistan