Pakistan’s tobacco epidemic is a public health crisis of staggering scale: 31 million users, 163,600 deaths yearly, and $3.85 billion in healthcare costs. As a dedicated advocate for tobacco control and harm reduction, I see a nation at a crossroads. Outdated policies, a regulatory void around harm reduction products (HRPs) like e-cigarettes, and oral nicotine pouches (ONP), and a decade-old data gap cripple our efforts. Now is the time for bold, evidence-based reform, anchored by a credible, independent survey led by Global Action to End Smoking (Global Ends), an organization uniquely positioned to deliver truth over agenda.
Tobacco Control: A Mixed Record
Pakistan’s commitment to the WHO Framework Convention on Tobacco Control (FCTC) has yielded measures like smoke-free laws, graphic health warnings covering 60% of cigarette packs, and advertising bans. Taxation, a critical lever, saw a 153% Federal Excise Duty hike in 2023, aiming to make cigarettes less affordable. Yet, the reality is sobering. Enforcement is inconsistent—86% of adults face secondhand smoke in restaurants. Cessation programs are scarce, with only 24.7% of smokers attempting to quit. Smokeless tobacco, like gutka and naswar, thrives in regulatory shadows, culturally entrenched and cheaply sold.
The illicit cigarette trade, now 42% of the market according to ffoglobal.com’s 2024 report, is a glaring failure of tax administration and the Track and Trace System launched by FBR. These untaxed products, smuggled or counterfeit, keep prices low—$ 0.5 per pack—and rob the treasury of funds for health programs. Pakistan’s policies, built decades earlier than the 2014 Global Adult Tobacco Survey (GATS) first and last so far, are outdated. GATS reported 19.1% adult tobacco use but misses today’s trends: rising HRP use, youth behaviors, and tax impacts. Relying on a decade-old snapshot is like treating a patient with an expired diagnosis.
Harm Reduction: Potential Amid Peril
HRPs—e-cigarettes, heated tobacco products (HTPs), and nicotine pouches—are reshaping Pakistan’s tobacco landscape. In Karachi and Lahore, vape shops and online platforms buzz with products, drawing smokers seeking alternatives and youth chasing trends. A 2022 study found that 13.9% of medical students had tried e-cigarettes, hinting at a broader uptake. Globally, HRPs show promise: the UK’s Royal College of Physicians deems e-cigarettes 95% less harmful than smoking, and Sweden’s nicotine pouches helped cut smoking to 3.7%, among the world’s lowest.
Yet, Pakistan’s HRP market is a regulatory Wild West. Untaxed and unmonitored, these products risk hooking non-smokers while offering smokers unverified options. Dual use—vaping alongside cigarettes—is common, diluting benefits. Without oversight, we’re gambling with public health. The UK offers a model: HRPs are regulated for safety, taxed lower than cigarettes to encourage switching, and restricted to adults. Pakistan could adopt a tiered framework, prioritizing cessation while safeguarding youth.
The Data Void: Why Global Ends Is the Answer
Effective policy demands current, unbiased data. The 2014 GATS, silent on HRPs and post-tax trends, is obsolete. Past surveys, often funded by groups skeptical of harm reduction, skewed narratives toward prohibition, ignoring e-cigarettes’ role in quitting. A new national survey is urgent, capturing:
• Tobacco and HRP prevalence by age, gender, and urban/rural divide.
• Dual use, cessation attempts, and illicit trade (42% of cigarettes).
• Perceptions of HRP risks versus benefits.
• Policy impacts, like tax hikes and ad bans.
Global Ends, led by President and CEO Cliff Douglas, is the ideal partner. Once misjudged as a tobacco industry proxy, Global Ends has transformed since Douglas’s 2023 appointment. His 36-year crusade against Big Tobacco—pioneering airplane smoking bans, and shaping federal lawsuits—earned global trust. In 2023, the Foundation for a Smoke-Free World, under Cliff Douglas’s leadership, received a final $140 million payment from its donor as part of terminating their funding agreement, with bylaws amended to prohibit future tobacco or non-medicinal nicotine industry funding.
Studies like the 2023 Doctors’ Survey, exposing nicotine misconceptions, cement Global Ends’ rigor. It’s no mouthpiece; it’s a leader in harm reduction research, free from ideological or industry sway.
Challenges for Global Ends in Pakistan
A Pakistan survey post-2024 regime change isn’t simple:
• Political Flux: Shifting priorities may stall approvals. Global Ends must align with local health bodies to navigate the bureaucracy.
• Cultural Nuances: Tobacco’s deep roots, especially smokeless forms, demand surveys in regional languages, sensitive to rural norms.
• Skepticism: Anti-tobacco groups may question Global Ends’ past. Transparency—open datasets, academic oversight—will counter doubts.
• Illicit Trade: Mapping 42% of illicit cigarettes requires retail audits and informant networks to pierce underground markets.
• Youth Trends: HRPs’ digital appeal needs online surveys, tricky in low-connectivity areas.
Global Ends’ work in low-income nations, supporting proves its mettle. Its global reputation ensures credibility where others falter.
A Roadmap for Reform
Pakistan must act decisively:
1 Bolster Enforcement: Fine smoke-free violators, ban youth sales, and fund cessation clinics with nicotine replacements.
2 Regulate HRPs: Mandate safety standards, curb flashy ads, and tax HRPs below cigarettes, as Sweden does, to nudge smokers toward safer options.
3 Tax Smartly: Implement a track and trace system in its letter and spirit to capture tax-avoided products and include them in the tax net, improve tax administration, and harmonize smokeless tobacco levies.
4 Launch a Survey: Partner with Global Ends for a 15,000-household study within 18 months. Fund it transparently—global health bodies, not agendas—and share raw data to build trust.
A Healthier Future Awaits
Tobacco’s grip—millions addicted; billions spent—demands urgency. Harm reduction, paired with robust controls, offers smokers a lifeline without normalizing nicotine for youth. Global Ends, under Cliff Douglas’s principled leadership, can deliver the data to guide us. Let’s reject fear, regulate wisely, and fund facts over fiction. Pakistan can lead the region toward a healthier tomorrow, but only if we act now.
Dr Ziauddin Islam
Tobacco Control and Harm Reduction Advocate
Ziauddin.islam@gmail.com