Smokeless Tobacco Regulation and Policy
Key provisions in the WHO Framework Convention on Tobacco Control as applied to Smokeless Tobacco (ST) has been implemented to varying degrees in some countries, but not others. Almost all of the provisions in the FCTC have direct and distinct implications for ST products and, to be fully implemented, will require guidance specific to ST products. For example, demand-reduction measures—such as regulation of tobacco product contents, packaging and labeling, education and communication efforts, and dependence and cessation interventions—should be tailored to ST product users and to the context of their use. Additionally, WHO Tobacco Regulation committee has published recommended upper limits for key tobacco carcinogens in ST products.
Countries and regions have had varied regulatory experiences, ranging from banning all or some ST products (Singapore, Brazil, Bahrain, the United Arab Emirates, and the European Union except Sweden), following FCTC recommendations for ST products (Turkey), prohibiting ST sales to minors, restricting promotion, and requiring product reports by manufacturers (United States and Canada), requiring text-based warning labels on ST products ( the United States, Canada and India), to a total absence of regulation of ST (most countries in the Eastern Mediterranean Region).
Key challenges :
(a) Low cost, high social acceptance, and easy availability of ST products;
(b) Tax evasion due to illicit sales and production in traditional markets, and illicit trade and low levels of taxation in other markets;
(c) Lack of standards for testing ST products;
(d) Industry marketing strategies for ST;
(e) Heterogeneity of ST products in their composition and their manner of production, sale, and use;
(f) The introduction of newer tobacco products, which may impact efforts to quit tobacco use and may lead to dual use or use of multiple-tobacco products.
To support product regulation and control, research is needed on regular surveillance and monitoring of ST products, including laboratory testing, sales and pricing data, marketing and packaging, and consumer response.
Additionally, research is needed on the characteristics of diverse products, their manner of use, and the effectiveness of policies and interventions in a variety of environments. Capacity building will also be needed to support laboratory testing and regular data collection on smokeless tobacco products.
Overall, policies and regulation to control ST product use have been given less support by governments and public health leaders compared with efforts directed at cigarette smoking. Policies and interventions targeted to ST products should be an integral part of any comprehensive tobacco control policy and regulatory regime.
South-East Asia Region Key findings:
Prevalence of ST use among men is high across most of the region, varying between 25 percent and 51 percent in five countries, but less than 2 percent in Thailand.
Among women, ST use is high in India (18.4 percent), Bangladesh (28 percent) and Myanmar (16 percent). Prevalence is also high across the region, equivalent to cigarettes, among youth aged 13 to 15 years.
This region is home to over 250 million ST users aged 15 and older. Rural users in India and Bangladesh make up 80 percent of total ST users in the world. Smoking remains more common than ST use in Indonesia, Thailand, Bangladesh, Sri Lanka, and Nepal, but ST use is predominant in India and Myanmar among men.
In India, the most common forms of ST used are tobacco with lime (khaini), gutka, and betel quid. Betel quid is typically freshly prepared by the user or a vendor. Pan masala and gutka have become increasingly popular as alternatives to traditional betel quid; they are manufactured on an industrial scale and sold in dried form.
High levels of TSNAs have been recorded in some products, including khaini and zarda. Areca nut used as an ingredient in betel quid contains additional harmful constituents. The fact that some products are produced and sold in cottage industries complicates efforts to characterize typical products in the region.
Incidence of oral and pharyngeal cancers is high in South-East Asia Region countries compared to most of the rest of the world, and this high rate has been attributed in large part to ST and areca nut use. Historically, only 10 percent to 15 percent of people with oral cancer in India are diagnosed when their cancers are in an early, localized stage, which results in poor survival rates.
Most of the epidemiologic studies of specific health effects of ST use in the region come from India. Studies have documented associations between ST use and oral precancerous lesions, oral cancers, adverse reproductive outcomes, and cardiovascular diseases.
A number of intervention programs—including school-based interventions, community interventions, and mass media campaigns, primarily in India—have been evaluated and shown to have some impact in the region. However, resources and capacity for large-scale intervention programs are limited in some countries.
All member states in the region except Indonesia have ratified the FCTC. However, implementation of ST control policies in the region has been limited.
In contrast to cigarettes, taxes on ST products are low or nonexistent. Unprocessed tobacco sold in loose form, including betel quid with tobacco, is often not taxed and does not display any package warning labels. Some countries have prohibited advertising of ST, including Bhutan, India,the Maldives, Myanmar, Sri Lanka and Thailand. Bhutan has banned the sale of all forms of tobacco, and several States in India have used national food safety regulations to ban gutka.
Future Research Needs Key findings:
A wide range of research gaps remain in relation to understanding and addressing the global public health impact of ST products. Research needs include ongoing surveillance of patterns of use across product types, further characterization of diverse ST products and their constituents, assessment of the health consequences of using different products in different regions, evaluation of the economic impact of ST use and the impact of taxation policies across regions, as well as assessment of cost-effective, region-specific ST education, prevention, and treatment interventions.
Implementation of effective strategies for control of ST use and related health effects will require increased scientific and public health capacity, particularly in low- and middle-income countries affected by high burdens of ST use.
International collaboration and shared capacity building could be applied to:
(a) Create regional, but globally accessible information clearinghouses for ST;
(b) Strengthen infrastructure for networking, communication, and collaboration and
(c) Develop ways to build research capacity by leveraging existing resources.
Collaborations are needed across disciplines and professions, such as between scientists, policymakers, and tobacco control advocates.
Prevention and cessation of ST use should be fundamental to every comprehensive tobacco control effort. In all regions, greater awareness is needed about ST use and its health effects, including education of health professionals, consumers, policymakers, and community leaders. Effective interventions tailored specifically to ST users should be developed, evaluated, and implemented where appropriate.
Specific guidelines are needed to ensure that the WHO FCTC requirements can be and are appropriately applied to ST products as well as cigarettes. Such guidance must also take into account the diversity of product types, patterns of use, and local contexts that are found around the world.
A range of policies have been proposed or implemented for ST products in some countries, but data are often lacking on their impact or effectiveness.
Greater attention should be directed toward strengthening of the use of evidence-based policies for controlling ST use.
These policies could include: Requiring tobacco industries to disclose the contents of ST products; establishing performance standards for toxicants and maximum pH levels; banning flavorants; establishing effective and relevant health warning labels; increasing taxes on ST products; banning or restricting ST promotions, sponsorship, or marketing; and raising public awareness of the toxicity and health effects of ST products.
ST is used in various forms throughout the world. All ST products contain nicotine, and ST users’ exhibit characteristics of nicotine addiction similar to cigarette smokers.
Smokeless tobacco products contain numerous known carcinogens, although in varying levels depending on product characteristics such as type of tobacco, additives, alkalinity, and processing methods. Many products also contain other plant materials (areca nut or tonka bean) or additives that may be carcinogenic or have other adverse health effects. For this reason, the assessment of health risks associated with ST products should include not only tobacco, but also the more complex mixture of ingredients that may further increase risk.
Much of the world’s population is unaware of the dangers of using these products, and marketing efforts by the tobacco industry further distort the dangers. Even in high-income countries where information about the harms of tobacco use is more widely available, the tobacco industry has been marketing ST products as a safer substitute for cigarettes among adult smokers and adolescent initiators, particularly for use in situations where smoking is not allowed or where the smoker wants to use tobacco discreetly.
Increasing public awareness of the risks and consequences of using ST products is critical to safeguarding public health. Depending on the country or region, this can mean combating long-held local customs as well as industry marketing efforts by delivering accurate information to dispel myths about ST use and explain the hazards of dual use of ST and cigarettes. Adolescent, school health, and maternal–child health programs are valuable means of educating the public about ST use.
It is essential that information and evidence about smokeless tobacco use be disseminated among policymakers, researchers, and other professionals in order to establish programs to combat ST use and ameliorate its effects.