According to Global Adult Tobacco Report Pakistan, 2014, “With 24 million active smokers, Pakistan has one of the world’s largest number of tobacco users.” Although exact figures are not available for the country’s under-age smokers, a research paper on the Pakistan Journal of Medical Sciences website by Noreen Shah and Saad Siddiqui, titled An overview of smoking practices in Pakistan (2015) based on a study of 613 research articles, found that a majority of studies reported adolescence as the time of initiation of smoking.

The figures reflect the absence of a holistic policy approach to discourage smoking, especially at an early age. That eventually leads us to the debate about growing and taxing tobacco products.

Laiquat Yousafzai, the Tobacco Growers’ Association president, tells TNS that tobacco business in Pakistan is worth over Rs 400 billion, out of which the farmers earn nearly 22 billion. “In 2019, the federal government collected over Rs 150 billion in excise duty and the federal tobacco cess on tobacco products. The Pakistan Tobacco Board also makes hefty amounts in different taxes.”

Tobacco farming and processing are a source of income for over half a million people in KP. More than 1.5 million people are associated with the production, promotion and selling of tobacco products across Pakistan.

Growing tobacco comes at a high cost. Labourers at various stages of its production face different health hazards. The trained farm workers, mostly young males, are exposed to hazardous fluids as they use poisonous sprays on the crop. Child workers, women and young males process tobacco leaves without adequate protection. “But the most dangerous job is inside the burners. The workers are exposed to 55 to 60 degree Celsius in July and August and often end up being diagnosed with tuberculosis or respiratory diseases,” says Yousafzai.

The taxes collected on tobacco are insignificant compared to the amount spent on the treatment of patients with tobacco-attributable diseases. A study published earlier this month by the Pakistan Institute of Development Economics (PIDE), titled The economic cost of tobacco-induced diseases in Pakistan, studied some 12,298 households and their smoking members across the country. It reported that costs attributable to all smoking-related diseases and deaths in Pakistan for 2019 stood at Rs 615.07 billion while the tax contribution of the tobacco industry was 20 percent of the cost of smoking at Rs 120 billion.

According to the study, 71 percent of the smoking-induced costs came from cancer, cardiovascular and respiratory diseases. The total direct and indirect cost of the three smoking-attributable diseases amounted to Rs 437.76 billion, which was 3.65 times higher than the overall tax revenue from the tobacco industry. Furthermore, total smoking-attributable costs were 1.6 percent of the GDP, while costs of the three diseases were 1.15 percent of the GDP. The smoking-attributable direct cost is 8.3 percent of the total health expenditures.

In a study titled, Regional tobacco regime and its implications for health, conducted by Sustainable Development Policy Institute (SDPI) in January this year, lowest tax on cigarettes results in revenue loss in Pakistan and increase in cigarette consumption. According to WHO, “On average, a ten percent price increase on a pack of cigarettes would be expected to reduce the demand of cigarettes” by about five percent in low and middle-income countries.

Prof Dr Sher Muhammad Khan, renowned oncologist and former director of Peshawar’s Institute of Radiotherapy and Nuclear Medicine (IRNUM), believes that tobacco is the main reason behind several types of cancers in the country. “There is no doubt that tobacco consumption is harmful for humans. It causes heart diseases and cancers of lungs, mouth and throat. One of our surveys found that most cancer patients in the southern districts of KP suffer from mouth and throat-cancers due to the use of naswar,” he added.

Dr Khan says that his team studies some 30,000 cancer patients from Khyber Pakhtunkhwa (then NWFP) and Afghan refugees in 1997 and found that most males had smoking-attributable cancers. “Treating any cancer is an expensive business. Investigations involving X-rays, CT and MRI scans are expensive and not available everywhere so the health centres with such facilities are always under tremendous stress. In most cases, cancers are treated with expensive surgeries and chemotherapies, which require importing costly chemo medicine. Radiation, too, is done with expensive equipment imported from foreign countries,” says Dr Khan.

“Medical studies have the highest stress levels and some students take refuge in smoking to cope with the stress involved. Our survey reported that 45 percent of first year students smoked cigarettes. The percentage dropped down in the 2^nd, 3^rd and 4^th year. However, it went up to 41 percent in the final year as the stress increased. Choosing smoking as a fashion was less than 10 percent, says Dr Razaullah, assistant professor of pulmonology at the Hayatabad Medical Complex, Peshawar.

“I can say that 15 to 20 percent burden on hospitals can be reduced with the reduction in the number of smokers. But it needs a strong initiative by the government and society to achieve this goal,” he adds.

Dr Razaullah points to another important aspect about smoking. “We have seen very few smokers seeking medical attention to quit smoking. The clinics in the public sector where pulmonologists can encourage smokers to quit smoking through counselling can help a lot,” he says.

According to experts, each year, over 100,000 deaths in Pakistan are attributed to tobacco use, most of those due to cancers, ischemic heart and other cardiovascular and respiratory diseases.

The World Health Organisation’s Framework Convention on Tobacco Control (FCTC), to which Pakistan is a signatory since 2005, requires signatories to optimally impose a 75 percent tax on the retail price of cigarettes.

According to the WHO, “Fighting tobacco in Pakistan will require a strong commitment to the WHO’s FCTC and the related strategies. These are proven strategies that can help avert unnecessary illness and death.”