Lack of smoking cessation services - a missing link in Pakistan’s tobacco control

After two decades of campaigns against smoking, Pakistan has reported an annual death rate from smoking of 91.1 per 100,000 people, notably higher than the averages for South Asia (78.1) and the rest of the world (72.6). This is an extremely worrying development for a country that the World Health Organization (WHO) has awarded for its tobacco control initiatives.

Pakistan's tobacco control campaign has not been without success. In 1997, Pakistan took the first step of banning tobacco advertisements on electronic media - mainly Pakistan Television. This was the step to ending the ubiquitous smoking ads in print and electronic media. Today we do not see ads for cigarettes anywhere in the country.

After ratifying the FCTC, Pakistan focused on disrupting the access of smokers to cigarettes – a task in which it failed miserably. Pakistan introduced pictorial health warnings (PHWs) on cigarette packs in 2009. These warnings are periodically updated and currently cover 60% of the front and back of cigarette packs. However, the target is to cover 80% of the pack with the PHWs.

Similarly, to discourage tobacco consumption, the government has increased taxes on cigarettes and other tobacco products. Pakistani substantially increased the Federal Excise Duty (FED) on cigarettes during the fiscal year 2022- 23. However, because of the increase in the prices of premium to economy brands, smokers switched to cheaper brands and bought loose cigarettes. This is despite the fact that the sale of loose cigarettes is banned. There is also a ban on sale of tobacco products within a 50-meter radius of educational institutions, though its implementation remains an issue.

However, one area that Pakistan has ignored completely is the provision of smoking cessation services. Pakistan lacks a comprehensive, government-supported national smoking cessation program. While some private organizations and NGOs run small-scale initiatives, their limited reach and resources prevent them from addressing the issue at a national level.

Additionally, many tobacco users are unaware of the availability or importance of cessation support. Public awareness campaigns rarely emphasize smoking cessation as a viable option, focusing more on the harms of tobacco use. This limits demand for such services and leaves smokers without motivation or knowledge about how to quit.

There is also a shortage of trained healthcare professionals specializing in smoking cessation. Doctors, nurses, and counselors often lack the necessary training to provide evidence-based cessation advice, behavioral therapy, or pharmacological interventions.

Smoking cessation services are not integrated into primary healthcare systems. Routine consultations in clinics and hospitals seldom include discussions about smoking cessation or referrals to specialized services, missing critical opportunities to engage smokers.

Pharmacological aids such as nicotine replacement therapy (NRT) and prescription medications for smoking cessation are not subsidized or widely available. Their high cost makes them unaffordable for many tobacco users, particularly those from low-income backgrounds.

In Pakistan, cultural and social factors also hinder the uptake of cessation services. Many smokers view smoking as a personal choice and are reluctant to seek help, while societal stigma can discourage others from accessing support.

A future without combustible smoking is possible in Pakistan. There is a need to develop and implement a nationwide smoking cessation strategy. This should be backed by establishing smoking cessation clinics in public hospitals across all provinces and districts, training healthcare professionals in cessation techniques and counseling, and providing affordable or free access to NRT and cessation medications. There is also a need to include cessation counseling in routine health check-ups.

The lack of adequate smoking cessation services in Pakistan is a critical gap in the country's tobacco control efforts. Addressing this issue through targeted interventions and resource allocation can significantly reduce tobacco-related morbidity and mortality while improving public health outcomes.