Tobacco Harm Reduction in Afghanistan: A Recipe for Improving Smokers' Health

doi:10.21203/rs.3.rs-1751093/v1

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Tobacco Harm Reduction in Afghanistan: A Recipe for Improving Smokers' Health

https://doi.org/10.21203/rs.3.rs-1751093/v1

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Almost three million Afghans smoke daily, the majority of whom are teenagers. Smoking is responsible for the deaths of thousands of Afghans every year. The previous Afghan government made significant efforts to control and reduce tobacco use through tobacco cessation policies and strategies. However, these policies were not effective in reducing the number of smokers and smoking-related deaths. Hence, there is a need to introduce and implement novel, realistic, and practical approaches that have been proven effective in smoking abstinence and minimizing tobacco harm. Community-based initiatives in Kabul and Herat have started advocacy campaigns since 2021 and tried to increase people's awareness of the tobacco harm reduction (THR) concept, paving the way for adopting new policies. Implementing these strategies in Afghanistan is likely to face many challenges. The current government’s low priority for tobacco harm reduction research and advocacy, funding issues, unfavorable market conditions for THR products and their high cost-effectiveness, THR product-related misconceptions, and the total prohibition of all tobacco products without any exception in Islam are the significant challenges. These obstacles can be overcome with effective THR policymaking that will promote THR products for smokers, market support and regulation, local and domestic manufacturing with healthcare professional oversight, conducting more engaging advocacy campaigns, and securing domestic sponsors.

Tobacco

Harm reduction

Smoking

Tobacco Harm Reduction

Afghanistan

Tobacco products are used by an estimated 1.3 billion individuals globally, with more than 80% living in low- and middle-income (LMIC) countries. Due to its addictive nature, it is hard to curb its spending behavior [1, 2]. The tobacco epidemic is one of the world's most serious public health threats, killing more than 8 million people each year. More than 7 million deaths are directly related to tobacco use, whereas around 1.2 million are related to nonsmokers exposed to second-hand smoke [2]. Tobacco use is the major avoidable cause of disease, disability, and death. Tobacco smoking can result in lung cancer, chronic bronchitis, and emphysema. It is also responsible for an increased risk of heart disease, stroke, neurological disorders, reproductive complications, premature skin aging, osteoporosis, psychiatric disorders, leukemia, cataracts, type 2 diabetes, and pneumonia [3].

In response, over the last two decades, a significant global effort has been directed toward reducing the tobacco epidemic, specifically, since the World Health Organization adopted the Framework Convention on Tobacco Control in 2003 [4]. This was the world's first public health treaty, promoting smoke-free legislation and organizing the implementation of a national tobacco control program based on MPOWER policies. To recognize the impact of tobacco smoking, in 2015, the 2030 Agenda for Sustainable Development included stronger tobacco control as a global development goal [5].

Nicotine is the addictive component of tobacco with brief to no cardiovascular effects which poses no risk of respiratory disorders such as chronic obstructive pulmonary disease or cancer [6]. This correlates to the modern smoking cessation strategy known as Tobacco Harm Reduction (THR), which tries to reduce the health risks associated with tobacco use by encouraging the use of alternative nicotine products such as e-cigarettes, snus, etc [7]. ST products, NRT, and e-cigarettes would result in reduced or no exposure to carcinogens and other harmful substances while still supplying nicotine [8]. THR is a public health strategy that aims to reduce the health risks associated with tobacco use in individuals and society. Tobacco smoking is recognized as a primary cause of illness and death [9], and smoking cessation is critical to public health [10]. However, smoking/tobacco abstinence is challenging, and even approved smoking cessation therapies have a low success rate [9]. Even so, some smokers may be unable or reluctant to quit smoking [3].

Nicotine is like opioids, alcohol, and cocaine in terms of drug dependence, which often reinforces relapse after tobacco abstinence, rendering most attempts at smoking cessation unsuccessful. According to a 2006 national Institute of Health (NIH) consensus conference on tobacco use, 70% of smokers want to quit, and 40% make a serious attempt at it each year in the US, but fewer than 5% succeed in any given year [3]. Therefore, providing low-harm alternatives to smokers results in a lower total population risk than adopting abstinence-focused programs [11]. These low-harm alternatives include modern Smokeless Tobacco (ST), E-cigarette products, and Nicotine Replacement Therapy (NRT), such as nasal snuff, chewable tobacco, oral snuff, and nicotine medications, e.g., nicotine gums and patches.

Compared to smoking cigarettes, using ST is relatively safer and associated with fewer health risks. Numerous epidemiological studies and meta-analyses confirm that using ST is associated with minimal risk of cancer, myocardial infarction, and stroke [12]. E-cigarette use mimics cigarette handling routines and cues of smoking, a psychological craving unrelated to nicotine, leading to a more viable smoking cessation without any withdrawal symptoms. THR has the potential to lead to one of the greatest public health breakthroughs in human history by considerably decreasing the forecasted one billion cigarette-caused deaths this century [12].

Numerous governmental surveys and one clinical trial conducted in the US suggest that a significant number of smokers have quit smoking by substituting ST products for cigarettes and that ST products are efficient in helping smokers become smoke-free. Due to their different tobacco consumption (i.e., Swedish snus), Swedish men have had the lowest rates of smoking-related cancers of the lung, larynx, mouth, and bladder in Europe over the last 50 years, as well as the lowest percentage of male deaths related to smoking of all developed countries. Over 60% of nicotine consumption among Swedish men is from snus. The Swedish tobacco experience proves ST to be safer than smoking tobacco [3].

E-cigarettes are both used as tobacco substitutes for long-term abstinence and as a smoking cessation aid. It is a unique harm reduction innovation because according to some vapers, e-cigarettes are preferred, over time, to tobacco smoking and have surpassed tobacco smoking in popularity making them much more than just a smoking substitute. Furthermore, scientific evidence indicates that e-cigarettes are 95% less harmful than tobacco smoking. Hence, vaping (e-cigarettes) has become quite popular as a smoking quitting tool and a harm reduction approach among the United Kingdom medical and public health bodies [13].

Overall, effective tobacco harm reduction requires the availability of scientifically substantiated less harmful products, such as ST and e-cigarettes, to the public. Consumers should have access to science-backed information, i.e., the relative harmfulness of each tobacco product, to make informed choices. This commentary aims to provide an overview of Afghanistan's tobacco control and THR state and offers recommendations for the effective implementation of THR policies.

Afghanistan adopted the WHO Framework Convention on Tobacco Control (FCTC) on November 11, 2010 [1, 14]. Additionally, several laws have been enacted to control tobacco use, including “The Bylaw for the Ban of Cigarette and Tobacco Use in Governmental Buildings and Public Places” in 2007, “The Tobacco Control Law” in 2015, “Ministry of Public Health Notice to Ministry of Foreign Affairs, Health Warning/Pictorial Labeling on Tobacco Products, Including Cigarette Packages” in 2016, and “The Amendment to the Tobacco Control Law” in 2018. However, none of the mentioned measures led to effective tobacco control in Afghanistan [14]. Based on the reports of WHO, current smoking rates are 35.2% among men and 2.1% among women. In the absence of better policies, smoking-related deaths will reach 1.74 million of the 3.5 million smokers alive, and the figures will predictably escalate each year [15].

The primary reasons for its failure were ongoing political violence, poverty, tobacco industry interference with tobacco control policies (i.e., political lobbying), rising corruption, failing state and political institutions, and vulnerability to corporate tobacco market expansion due to a weak economy. The former government’s inability to implement a tax increase on tobacco products, lack of health warning labels on tobacco products in pictorial form, and lack of a national anti-tobacco media campaign led to the failure of tobacco control in Afghanistan.

The previously enacted laws on tobacco revolved only around tobacco control policies, such as smoking prohibition in public and workplaces, tobacco price and tax increases, and the promotion of anti-smoking advertisements. These policies, and tobacco control policies in general, are not very effective in reducing combustible tobacco use among smokers, even if they are implemented successfully. The THR initiative in Afghanistan, for the first time, was introduced in 2021 with the primary aim of helping Afghan smokers switch to safer nicotine products to decrease tobacco smoking-related harms which will lead to greater success in abstaining from smoking. First started in Kabul and Herat Universities, the project was a joint research project and awareness campaign by THR Afghanistan, sponsored and supported by Knowledge Action Change, which aimed to inform the people about the harms of smoking and possible interventions for reducing these harms. Most of the activities involved social media engagement with people and supporters. The project's focus was on health workers and the general public, and it attempted to engage more people in community advocacy activities for THR [16]. The following paragraphs have elaborated on the most challenging issues against the effective implementation of the THR program.

Some NRT and e-cigarette products are not cost-effective, making them inappropriate as long-term alternatives to cigarettes. An effective tobacco harm reduction strategy requires the availability of low-cost smoking alternatives. Due to sanctions, e-cigarette/vaping products and their nicotine liquid, which are imported products, are scarce and unaffordable in the market.

Accordingly, since the collapse of the republic government, Afghanistan has been under severe international sanctions that have crippled the Afghan economy. Due to the sanctions and frozen assets, the government is struggling to keep the health and education sectors working, making THR advocacy and research a low priority for both the government and international humanitarian relief organizations. Implementing THR policies is challenging with the absence of proper financing and fundraising for THR advocacy programs and research.

On April 3, 2022, the supreme leader of the Taliban prohibited the cultivation and selling of narcotics, including tobacco, in Afghanistan [17]. It is unclear how they will enforce this ban on millions of farmers while the country’s economy crumbles. The new government lacks the adequate means for dealing with the consequences of such a ban and needs substantial international support. This ban is based on Sharia, Islam's legal system, which might have severe ramifications for THR efforts in Afghanistan since it prohibits any psychoactive substances including nicotine, including ST products.

Moreover, misconceptions and ignorance regarding THR products and tobacco consumption can pose a serious obstacle to THR in Afghanistan. There are allegations of ST being a gateway to smoking initiation, whereas it’s a gateway to smoking cessation. People, in general, excessively overstate the dangers of ST and other THR products such as NRT and e-cigarettes and are unaware that THR products such as ST are less dangerous than cigarettes. Unregulated and non-standard domestic and traditional ST products such as powdered tobacco dip (locally called "Naswar") are widely available and abundant. In Afghanistan, the most consumed ST product is Naswar. These non-standard and unsafe domestic ST products have been catalysts for the stigma against ST products in general and other misconceptions for a long time. There is a concern that youth might get addicted to THR products and that it will compromise tobacco prevention efforts and the goal of eliminating all tobacco use.

THR will require a rethinking of conventional tobacco control policies. Many experts argue for a market approach involving risk information on every tobacco product so that smokers can make informed decisions, dismissing misconceptions surrounding tobacco products. The labeling and marketing of tobacco products need to be regulated based on their risks and relative harmfulness. Smokers should be made aware that NRT, ST, and e-cigarettes are safer alternatives to combustible tobacco through health warning labeling on cigarette and ST packages such as: “Warning: Smokeless tobacco use has risks, but cigarette smoking is far more dangerous.", or "Quitting tobacco entirely is ideal, but switching from cigarettes to smokeless tobacco can reduce the health risks to smokers and those around them.", or “Notice: Nicotine does not cause cancer, heart disease, or emphysema” on NRT products [3]. Information provided by the government and health authorities should indicate the relative health risks of each tobacco and nicotine product rather than falsely suggest that all tobacco and nicotine products are equally harmful. Safer alternatives such as ST and nicotine medications should be promoted and marketed attractively by the health authorities for inveterate smokers and smokers who fail to quit [18]. Health risk-based tax policies need to be established for tobacco products because some tobacco products, like ST, pose fewer health risks than cigarettes and should be taxed according to their relative risks [3]. Without government interventions in the market, THR in Afghanistan will be a failure.

Furthermore, due to the sanctions, the scarcity and high cost of e-cigarettes and vaping products in the Afghan market present a significant hurdle for smokers attempting to shift to non-tobacco products. The best solution for the government is to reduce import taxes on these products and support domestic production of their e-liquids, making them more affordable and starting negotiations with the international community to lift sanctions. One of the most cost-efficient and accessible THR products in Afghanistan is Naswar. Because of its unregulated and non-standard local and domestic production, it has stigmatized and demonized all ST products to the point where most people, particularly smokers, believe they are more dangerous than cigarettes. The domestic tobacco industry can become a part of the solution to cigarette smoking by investing in ST products that meet the required quality standards and the needs of smokers. These companies must operate under a regulatory framework that focuses on the standard quality and safety of these products while also allowing for appropriate oversight of communication with smokers via advertisements. Afghanistan has several renowned pharmaceutical and tobacco companies that may leverage the numerous tobacco plants to generate enough standard ST products for an effective THR. Domestic production, with government support, would balance the market, favoring ST products.

As previously stated, the sanctions have cornered the government economically, and the humanitarian crisis resulting from it has made tobacco and smoking-related health issues a low priority for international aid organizations. Since there is insufficient funding for THR, the only option left is to locate domestic sponsors. Large commercial businesses that share mutual interests could support advocacy initiatives. Typically, universities and academic institutes are major financial supporters of advocacy research. This financing and support may be small and difficult to come by, but it has the potential to keep the advocacy going.

Engaging more people in the process is one of the primary success indicators of advocacy programs. Similar successful THR cases in African countries highlight the importance of collaboration among various institutions and organizations [19, 20]. Non-governmental organizations (NGOs), such as medical associations, student unions, youth activists, cultural institutions, local community hubs, and other institutions, could help the advocacy campaign expand and spread. Because Afghanistan is a religious country, enlisting the assistance of clergy and mosques is the most effective way to raise awareness. Furthermore, high schools and universities are the most appropriate places to raise youth awareness. People will be more likely to trust the THR if they see that their community and credible organizations support it. However, the media's power to inform the public is irreplaceable. In addition to raising awareness and clearing up misunderstandings, these alliances make cost-effective campaigning possible as volunteer activists conduct most of the advocacy.

Afghanistan has a higher smoking rate than other low and middle-income countries with a yearly death rate of 1.74 million. Tobacco control measures are not effective in significantly decreasing smoking-related morbidity and mortality, and on top of that, their implementation in Afghanistan was unsuccessful. The THR program is a promising initiative that will assist with smoking cessation and decrease harm from tobacco use in Afghanistan. THR policies such as health warning labels about the relative risk of tobacco products on the packaging of cigarettes, ST, and NRT products will enable smokers to make informed decisions and substitute cigarettes with other less harmful alternatives. Health officials should promote and advertise safer alternatives, such as ST and nicotine medicines. Because some tobacco products have fewer health hazards than cigarettes, tobacco products must be priced and taxed based on their relative dangers. The shortage and high cost of e-cigarettes and vaping products and the abundance of non-standard ST products in the Afghan market present a substantial barrier for smokers looking to switch to non-tobacco and less harmful tobacco products, which can be solved by lowering the import tax on e-cigarettes and NRT products and regulating the ST industry to ensure standard ST products. It is necessary to locate local and domestic sponsors and to collaborate with people’s trusted societies, associations, community and religious leaders, and media to promote THR awareness programs and research amid international sanctions and an economic crisis.

The acronym MPOWER stands for M: monitor tobacco uses and prevention policies; P: protect people from tobacco smoke; O: offer help to quit tobacco smoking; W: warn about the dangers of tobacco; E: enforce bans on tobacco advertising, promotion, and sponsorship; and R: raise taxes on tobacco

ST stands for Smokeless Tobacco products such as chewable tobacco, oral/nasal snuff, and Swedish snus.

NRT stands for Nicotine Replacement Therapy such as nicotine gums and patches.

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Not applicable

Consent for publication:

Not applicable

Availability of data and materials:

Not applicable

Competing interests:

The authors declare that they have no competing interests

Funding:

None

Authors' contributions:

All authors read and approved the final manuscript.

Acknowledgments:

With the support of Knowledge Action Change (KAC)

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No competing interests reported.

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Tobacco Harm Reduction in Afghanistan: A Recipe for Improving Smokers' Health

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Abstract

Background

Commentary

Challenges

Recommendations to promote THR in Afghanistan

Conclusions

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