Seminar Report – 'Tobacco Control: History and current global challenges'

On the blog today we have a guest post from Dr Victoria Turner (CGHH Associate & Public Health Specialty Registrar, Associate Clinical Fellow, Department of Health Sciences, University of York) who reports on the discussions at Global Health Histories Seminar 104.

Tobacco use remains one of the leading risk factors for mortality across the globe. It is therefore fitting that the 104th Global Health Histories seminar, held at the University of York, focused on this topic; in particular, shedding light on some of the less frequently addressed issues and their possible solutions.

Facing the Challenge: Tobacco Control in Sri Lanka 
The first speaker was Dr Lakshmi Somatunga of the Sri Lankan Ministry of Health, who shared her experience of using policy to improve tobacco control. She took us on a journey from the situation in 2000 where 25% percent of the Sri Lankan population were daily smokers (although less than 1% of females), and where vigorous promotion of smoking occurred in the media, to the present where Sri Lanka has a successful National Programme on tobacco control, effective national legislation (National Authority on Tobacco and Alcohol Act, 2007) and has taken an international lead on ratifying the Framework Convention for Tobacco Control. By 2015 smoking prevalence in Sri Lanka had decreased to 19.9% in men and negligible in women. The daily average number of cigarettes smoked by men had also decreased, from 9.1 in 2007 to 3.7 in 2015.

Key factors influencing the success of the Sri Lankan approach to tobacco control included:

• Strong political commitment 
• Very supportive media 
• Multi-sector involvement, led by the health sector 
• Strong promotion/prevention measures, such as early behavioural change in school children and the integration of tobacco control into health lifestyle messages 
• Inclusion of grass roots societies at stakeholder meetings 
• Visible and accessible state-run health services 

Dr Somatunga. Credit: University of York/ Alex Holland

I was particularly interested to hear about the integration of tobacco control into the school curriculum, with compulsory questions on tobacco control in general knowledge exam papers (although as Dr Somatunga later pointed out, there is sometimes a difference between what you know and what you choose to practice!)

Smokeless tobacco use in South Asia: health risks and control measures
Dr Somatunga’s presentation was followed by a talk by Kamran Siddiqi, Professor in Public Health at the University of York, who discussed the prevalence, risks and diversity of smokeless tobacco usage in South Asia.

We discovered that smokeless tobacco use is a sizeable, if underappreciated issue; of 1 billion smokers in the world, 25% are smokeless tobacco users. Despite this, very few countries regulate smokeless tobacco, and they are also usually subject to lower taxes and less stringent health warnings than cigarettes.

Professor Siddiqi. Credit: University of York/ Alex Holland

The variation between different smokeless tobacco products also makes this situation more complex. It was not only enlightening to hear about the different types of smokeless tobacco products, but also to appreciate that they all carried different risks. Prof. Siddiqi gave us a brief lesson in tobacco chemistry and demonstrated that products with different pHs carry different risks; the more alkaline, the higher the absorption into the body (including of carcinogens). There are also many different production methods at different scales, including those prepared by individual users, custom made products or manufactured products (either on a small local or a large industrial scale). This persistent diversity makes it very difficult to have a single policy against all forms of smokeless tobacco.

Prof. Siddiqi also emphasised the deep rooted cultural associations of smokeless tobacco use in South Asia, where it is used at weddings, religious celebrations, and other family gatherings. This makes tackling smokeless tobacco use more complex; a new NIHR Global Health Research Group called ASTRA (Addressing Smokeless Tobacco and building Research capacity in south Asia) has been set up to try and understand and overcome some of these issues, with University York staff (including Prof. Siddiqi) particularly involved.

Continuing the conversation
Following the presentations, Dr Nils Fitje of the WHO Regional office for Europe chaired a discussion with both speakers, who answered a variety of interesting and thoughtful questions from the audience.

Credit: University of York/ Alex Holland

Highlights included Dr Somatunga’s response to how smokeless tobacco was being challenged in Sri Lanka, which involved trying to build smokeless tobacco control into the current ‘fashionable’ ideal of keeping the environment clean, with children and young people once again cited as key agents for change.

Both speakers also made interesting points on the role of community leaders in behaviour change. Prof. Siddiqi discussed how faith leaders (Imams) in Bangladesh had requested training on advocating for smoke-free homes, and who were now using sermons as powerful way of delivering messages to particular communities. Similarly, Dr Somatunga discussed the success in Sri Lanka of getting senior Buddhist leaders to remove tobacco from betel offerings; a key part of religious ceremonies.

Both the presentations and the Q&A session highlighted the influence of culture on tobacco use, and the importance of challenging social norms in innovative ways in order to overcome the tobacco use (of many kinds) ingrained part of South Asian cultures.