Over 0.4m children start smoking every year
Maria Tabassum
PESHAWAR: Statistics suggest that around 1200 Pakistani children between the ages of six to 15 start smoking every day. It makes more than 0.4 million per year. A very meager number of them reach psychological help to quit the addiction while others grow up to be habitual smokers.
Some days back, my friend’s 10 grader informed her that some students in his class were caught with vape. When investigation into the matter was carried out by the school administration, it was discovered that the two students had contributed money to buy the vaping (electronic cigarette) device costing almost Rs 5,000 that they used to take home in turns to smoke.
The term vape or e-cigarette was something new to me that made me to search about it. Leaves of Nicotiana are used in various ways for smoking, snuffing, chewing, and extracting nicotine. Originally indigenous to the Americas, today’s cultivated tobacco has been highly engineered for consumption and nicotine extraction.
Prior to the 15th century, tobacco plant was grown and used in Americas. From 16th to 18th century, tobacco was smoked primarily in pipes and cigars, chewed and snuffed. In 19th century, cigarettes were introduced and became the most commonly used tobacco product globally. In 21st century, the tobacco products landscape continued to expand to include little flavored cigars and cigarillos, e-cigarettes, heated tobacco products (HTPs), and synthetic nicotine products. Nowadays tobacco in being used in oral nicotine products, smokeless tobacco products, combustible tobacco products, HTPs, hybrid devices and e-cigarettes.
E-cigarettes come in disposable and refillable forms and with prefilled cartridges and pods. These are called e-cigs, vapes and electronic nicotine delivery systems (ENDS). These are battery operated devices that heat a liquid to produce an inhaled aerosol. The liquids in e-cigarettes usually contain nicotine as well as flavoring and other chemicals. E-cigarettes come in a variety of shapes and sizes.
In 2020, 22.3 percent of the world population including 36.7 percent of men and 7.8 percent of women used tobacco. About 8.7 million people around the world die of tobacco use every year including 1.3 million those who are exposed to second hand smoke. Smoking tobacco can cause cancer of various organs. Eight in 10 deaths from tobacco use occur in low and middle income countries while 80 percent of the people who use tobacco live in low and middle income countries.
Pakistan is one of the largest tobacco-consuming countries in the world. The country is second after India with highest use of smokeless tobacco. According to the Ministry of National Health Services, almost 23.9 million adults currently use tobacco in any form in the country. According to the Pakistan Household Integrated Economic Survey 2015-2016, 45% of the households in Pakistan were tobacco consumers. In the country, tobacco kills over 164,000 people each year. Almost 31,000 of these deaths are due to exposure to second-hand smoke. Overall, 10.9 percent of all deaths are caused by tobacco. The total economic cost of tobacco induced diseases in Pakistan in 2019 was 615 billion while revenue from tobacco taxation 2018-19 was 120 billion.
Talking about psycho-social factors that contribute to cigarette addiction in children, renowned psychiatrist Prof Dr Khalid Attaullah Mufti said that economic status played a pivotal role as one child in every big-sized unprivileged family was observed to fall into smoking and even drug addiction.
“In elite class, e-cigs have become a trend. Another factor is peer pressure. What one child does, others want to do it in replication. They take money from homes for it on different pretexts and their parents often do not know what their children are into,” said the former principal of the Khyber Medical College, Peshawar.
“Third group is that of deprived children whose parents have separated or they do not have good relationship. Clashes between parents and bad family atmosphere make them to do so. Stray children are also a big consumer of cigarettes,” said a practitioner, who is also the chief executive of Ibadat Hospital and head of Horizon NGO.
“According to the clinical records of the last five years, five to seven addicted children ranging from seven to 15 years of age visited my clinic every year. Most of them are above 10 years of age while some are also below 10. This year, more than 11 such children have visited the clinic so far. This menace has even reached the girls’ schools. Smoking is now becoming a trend among women as well. What a mother or father does, their children will definitely do as a norm,” said the doctor.
About the treatment, he said, “The addict has to undergo psychological assessment. Psychiatrist and psychologist assess the child. Their cognitive behavior therapy is done. We mostly prefer psychotherapy for children and do not prescribe medicines unless they have some other symptoms or irritability while psycho education is given to their parents.”
Now talking about the role of educational institutions, administrator of a famous educational network of the country said that parental responsibility was needed to curb smoking and drug addiction in children. In most of these cases, peer pressure was observed wherein an elder child introduced cigarettes or drugs to a smaller one.
The educationist with over 30 years of experience in the field added that such addictions developed in children due to negligence of parents who gave money to their children but did not have a check on them to see where did they spend that money. The children called for money from their parents and got e-cig devices with it.
“Some parents have bought mobile phones to their children due to which they come to know about modern tobacco products and start using them secretively,” she went on to say, holding joint family system also responsible for it, and added, “Parents come into competition thinking if another child in the family is having cell phone, why not their child, but after buying him or her a mobile phone, they do not keep a check on its usage.”
About her institution’s policies, she said that they kept a strict check on students to discourage smoking and drugs’ trends. Such a case happened once in six months. Strict disciplinary action was taken against the student and he or she was suspended so the others should learn a lesson and refrain from doing so.
In such cases, she continued, “The parents do not do what they are supposed to. They physically punish their child that is not enough. The child needs proper counseling. In a case, a student of 6th grade was caught with ice. His father was informed about it. He just punished his child while he should have confronted the provisions’ store owner in their locality who sold the drug to the child.”
She observed that another student who was recovered with VELO (oral nicotine pouches) told them that he bought it from a grocery store in his locality. When asked about awareness material’s inclusion in the curriculum, she opined that it might further increase curiosity among children about smoking.
There is a fundamental and irreconcilable conflict between the tobacco industry’s interests and public health policy interests. The World Health Organization (WHO) Framework Convention on Tobacco Control (WHO-FCTC) is the first international treaty negotiated under the auspices of WHO. It was adopted by the World Health Assembly on 21th May, 2003 and entered into force on 27th February, 2005.
Pakistan became a party to the convention on February 27, 2005 and ratified the FCTC Protocol to Eliminate Illicit Trade in Tobacco Products on June 29, 2018. There are 182 Parties to the WHO FCTC 2021, covering more than 90% of the world population.
The convention says that because their products are lethal, the tobacco industry should not be granted incentives to establish or run their businesses. Article 8 of the convention calls for protection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places. Article 11 prohibits misleading tobacco packaging and labeling; large health warnings covering 50% or more, but not less than 30%.
Similarly, Article 13 requires comprehensive ban of all tobacco advertising, promotion and sponsorship. WHO MPOWER says to monitor tobacco use and prevention policies, protect people from tobacco smoke, offer help to quit tobacco use, warn about the dangers of tobacco, enforce ban on tobacco advertising, promotion and sponsorship and raise taxes on tobacco.
Talking about our country, ban on tobacco advertising, promotion and sponsorship is in place. Tobacco packaging and labeling regulations have been imposed. Regulations on smoke-free places and sales restrictions are in place while there are no regulations on e-cigarettes and new tobacco products.
Cigarette (Printing of Warning) Ordinance 1979 is in place but there is no rule on warning on smokeless tobacco products. Prohibition of Smoking in Enclosed Places and Protection of Non-smokers Health Ordinance was introduced in 2002. In 2009, Pakistan introduced warning regulations – 40% textual and pictorial warning by 31st May, 2010. The Statutory Regulatory Order (SRO) 2017 increased the size from 40% to 50% by June 2018 and to 60% by June 2019. SRO 2020 establishes restrictions on tobacco advertising and promotion.
It is to be mentioned that Pakistan has imposed a ban on import of sheesha (tobacco and non-tobacco) and related substances. There is also a ban on free goods, cash rebates, free samples, discount or goods below the market value offered for the purpose of advertisement of tobacco or its products. The country has imposed a ban on manufacturing or offering for sale sweets, snacks and toys in the form of cigarettes that may appeal to any person under the age of 18. The country has also included harmful effects of tobacco messages in revised lady health worker’s curriculum and included smoking status indicator in TB patient card. Pakistan has developed National Tobacco Control Strategy 2022-2030 as well, which is another achievement.
Now talking about challenges faced by the country, there is no provincial legislation on tobacco. It needs to allow sub-national regulations that are stricter than the national laws. There are no cessation/counseling services for those who want to quit smoking. In the same way, there is no regulation in the country on new tobacco and nicotine products.
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