A shadow report on the implementation of the Articles of Framework Convention on Tobacco Control (FCTC) of WHO in Sri Lanka

Tobacco is one of the world’s leading health threats, and a main risk factor for non-communicable diseases (NCDs) including cancers, diabetes, chronic respiratory disease, and cardiovascular disease. In Sri Lanka, around 26 percent of adults use some form of tobacco, killing an estimated 20,000 Sri Lankans per year. Tobacco imposes a substantial economic burden. In 2012, worldwide, healthcare expenditures to treat diseases and injuries caused by tobacco use totaled nearly six percent of global health expenditure. In Sri Lanka, for tobacco-related cancers alone, medical treatment is estimated to cost LKR 5.6 billion annually.? In addition to inducing high healthcare costs, tobacco use can reduce productivity by permanently or temporarily removing individuals from the labor market due to poor health. When individuals die prematurely, the labor output that they would have produced in their remaining years is lost. In addition, individuals with poor health are more likely to miss days of work (absenteeism) or to work at a reduced capacity while at work (presenteeism).??

The Framework Convention on Tobacco Control (FCTC) of the World Health Organization is the only public health treaty in the world. Sri Lanka is a Party to this treaty and if the implementation of the provisions of the FCTC is improved at the national level many lives can be saved and reduce chronic diseases. Sri Lanka ratified the Framework Convention on Tobacco Control on 11 November 2003, being the first country in Asia and the fourth in the world to do so. In 2006, the government of Sri Lanka introduced tobacco-controlling laws and regulations in Sri Lanka under the National Authority on Tobacco and Alcohol Act (NATA), No. 27 of 2006. The Founding Chairman of the National Authority on Tobacco and Alcohol (NATA) was the late Professor Carlo Fonseka and except one, all the other Articles of the FCTC were implemented during his tenure - 2006-2015.

During his tenure, NATA relied heavily on the six policies subsumed in the??WHO's well-known MPOWER formula and they were implemented to varying degrees. From its very beginning, NATA also focused on discouraging children from smoking by curtailing access to the product. One main objective of NATA was to foster a generation of secondary school children by making them aware of the scientific evidence that active and passive smoking would seriously damage their health. In pursuit of this objective, NATA launched a project to adapt suitably and translate the WHO publication called Manual on Tobacco Control in Schools. Implementing this project was a joint venture of the Ministries of Health and Education which was in progress. Much energy was expended on raising public consciousness on the prohibition of smoking in all public places on the basis of the scientifically established premise that?"Your Cigarette is killing me".

Establishing of District Tobacco Control Cells (DTCCs) throughout the 26 health administrative districts in the country to ensure the control of tobacco use was an excellent and effective initiative introduced by NATA during this period. The DTCCs operated under the Regional Directors of Health and included representatives from the Police, Excise, and Education Departments among others. Deeply conscious of the importance of the role of the mass media in tobacco control, NATA worked in close collaboration with media personnel and secured their cooperation. One significant achievement in this area was the substitution of health warnings for the irritating and fruitless "mosaic mechanism" that had been used for obscuring television scenes depicting or glamorizing tobacco. Various NGOs worked hand in hand with NATA during this period.

Tobacco use has an enormous impact on public health and the quality of life. Children and youth deserve to be protected from tobacco and nicotine and the tobacco/nicotine industry.? Tobacco reduction can help to reduce healthcare demands and improve overall productivity. Tobacco and nicotine companies must be held accountable for their actions. Tobacco use kills over eight million people annually and effective treaty implementation is essential to reduce its burden on public health. The FCTC is an evidence-based treaty that has been credited with preventing two million deaths annually and over 30 million deaths in total. Tobacco control is considered to be a “best buy” for public health and it can produce enormous dividends.?

Cigarette prices are relatively high in Sri Lanka. But they are still relatively affordable. Therefore, it appears that there is room for further increases in tax rates and the simplification of the tax structure. Before the adoption of WHO-FCTC, the government considered tax earned through cigarette sales as a good source of income for a country. However, after the adoption of the WHO-FCTC, prudent policymakers perceive it as an instrument for public health more than a source of income for the government. WHO-FCTC points out that for every LKR 1 spent to administer and collect cigarette taxes, the government can expect to see LKR 724 in return over 15 years.?

?Smoking is prohibited in many indoor public places and workplaces and on public transport. However, smoking is permitted in smoking areas or spaces in airports, hotels having 30 rooms or more, and restaurants having a seating capacity of a minimum of 30 persons.?But Smoking is not banned in All Public Places, such as beaches, parks, or roads. Advertising through most forms of mass media that does not serve a legitimate purpose is prohibited.

In July 2012, NATA issued Tobacco Products (Labeling and Packaging) Regulations, No. 01 of 2012, which addressed the issue of false, misleading, or deceptive messages on tobacco products packaging and introduced pictorial health warnings to cover 80% of the total area of a packet, package or a carton. The regulation also required that information on the relevant constituents and emissions should be printed on tobacco packages. Every cigarette manufacturer of the different brands of cigarette products shall ensure that there shall be printed on any packet, package, or carton containing cigarette product, only one type of pictorial health warning of each category as is set out in the schedule to these regulations and such pictorial health warning shall be changed once in every six months.?

Sri Lanka further prohibits misleading packaging and labeling, which includes phrases like “light” and “low.” when describing tar and nicotine contents in tobacco products during manufacturing, importing, or selling smokeless tobacco products, this further forbids tobacco-containing e-cigarettes, and flavored, colored, or sweetened cigarettes.

The law prohibits the sale of tobacco products via vending machines and in educational facilities and schools. The law also prohibits the sale of smokeless tobacco products. The sale of tobacco products is prohibited for persons under the age of 21. Currently, it is 24.

The sale of e-cigarettes is prohibited. However, there are no restrictions on the use or advertising, promotion, and sponsorship of e-cigarettes. E-cigarettes are widely used among international school children.

Implementation authorities could identify and prioritize interventions that are common to different occupational groups who are on the use of smokeless tobacco. The most effective approach would be through discussions with the specific groups themselves. Qualitative studies in different settings are needed to confirm the determinants and methods of communication to curtail the use of smokeless tobacco.

Implementing consistent, national-scale education and public awareness campaigns in collaboration with the media to warn about the harms of tobacco use is essential.? Media campaigns should be strengthened to update the public on worldwide new developments relating to tobacco control.

Furthermore, tobacco control measures such as licensing of tobacco retailers; regulating e-cigarettes; increasing the level of fines and penalties for violating tobacco control laws and regulations; and using a portion of tobacco tax revenue to provide alternative livelihood support for tobacco farmers or tobacco cessation support should be considered. Strengthening the national capacity to comply with, monitor, and enforce tobacco control laws and regulations is also necessary, which would include increasing the number of public health inspectors and training police and excise officers on tobacco control.

Policymakers including NATA and the Ministry of Health Sri Lanka should take into consideration the implementation of the following regulations;

1) Increase tobacco taxation to reduce the affordability of tobacco products.

2) Expand the ban on smoking in public places to include all public spaces, and increase compliance with the law.

3) Run national-scale anti-tobacco mass media campaigns to increase awareness about the harms of tobacco use.

4) Enact a comprehensive ban on tobacco advertising, promotion, and sponsorship.

5) Implement plain packaging of tobacco products.

6) Prohibit the sale of cigarette sticks individually.

7) Prohibit the sale of cinnamon cigarettes.

8) Reactivate the quit line of NATA which is not functioning due to financial crisis.?

The Ministry of Health and NATA should work with the Ministry of Finance and Planning to create an enabling environment for tax increases not just on cigarettes but on all tobacco products. It is important that tax rates are increased regularly and pegged to inflation and income growth to decrease the affordability of tobacco products. Equally important is the development of a robust strategy and systems to combat illicit tobacco trade, to prevent the loss of tax revenue for the government and the loss of lives, through the effective use of the Protocol to Eliminate Illicit Trade in Tobacco Products, which Sri Lanka acceded to in 2016.

The implementation of the regulations mentioned above will require strong political leadership and close collaboration among key stakeholders including the Ministries of Health, Home Affairs, Industry and Commerce, Education, Mass Media and Information, NATA as well as the media, civil society, academia, and UN and development partners.?

Currently, in Sri Lanka, we have a Health Minister and a Chairman, at the National Authority on Tobacco and Alcohol (NATA) who we strongly believe are sensitive towards the well-being of people and would take optimum action to implement and achieve the best results of the above-mentioned policy decisions.

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