Nepal has some of the strictest laws against smoking, but suffers from poor enforcement
Laxmi Ghimire is weak and tired after her sixth chemotherapy at the Oncology Ward of Bir Hospital in Kathmandu. She started smoking when she was 16, spent decades cooking on a smokey fireplace and now at age 61 her face is swollen, and she wears a red scarf to hide her balding head.
For the past decades, public health experts in Nepal have focussed on infectious diseases like diarrhoea and TB. But the burden of non-communicable diseases like cancer is increas-ing alarmingly, and today makes up nearly 90% of all hospitalisations.
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One important risk factor is smoking, and a 2015 survey found that 37% of Nepali men and 15% of women smoke. Nearly a third of adult males also regularly use smokeless tobacco.
“There is a direct correlation between the higher prevalence of lung cancer and smoking,” says oncologist Bibek Acharya at Bir Hospital who is treating Laxmi Ghimire. Nepal has the highest proportion of female adult smokers among South Asian countries, and the impact is seen in maternal and child health.
Tobacco consumption is falling in Nepal (see chart, below) but is still the cause of death of about 10% of men and women. Even so, Nepal is far ahead of other countries in the region in its anti-tobacco campaigns.
Last year Health Minister Gagan Thapa called for pictorial warnings to cover 90% of cigarette packs. The Ministry of Health announced that from mid-March tobacco products could only be sold in authorised shops. Nepal plans to introduce plain cigarette packaging by 2018, and make the country tobacco free by 2030.
“People’s attitudes have changed, no one serves cigarettes at parties anymore, and passengers have stopped smoking in public vehicles,” points out anti-tobacco activist Shanta Lall Mulmi. “We have some of the best anti-tobacco policies in the world. It is the implementation that has held us back.”
For example, the 90% pictorial warning on cigarette packs is only enforced for imported brands, the sale of tobacco products at licensed vendors has not gone into effect yet, the sale of cigarettes in public places isn’t strictly monitored.
Physician Anil Bikram at the Bharatpur Cancer Hospital agrees that continued easy access and indirect promotion in social media platforms are drawing younger people to smoking.
At the Ministry of Health Secretary Sailendra Raj Uprety admits that there is room for improvement. “The Health Ministry makes laws and policies, but for enforcement we need coordination with other agencies. We have to work harder on that.”
One way Nepal could further reduce smoking prevalence is to raise taxes. WHO recommends at least 70% excise on tobacco products, but Nepal has one of the lowest taxes in the region at 29%, far behind Sri Lanka (73%).
“We have to make it difficult for cigarette companies to sell their products by increasing taxes and enforcing plain packaging,” suggests cardiologist Prakash Raj Regmi.
Despite a gradual decline in tobacco production in Nepal, the industry is a lucrative source of revenue for the government, which collected Rs 9 billion in excise from tobacco products, contributing 4.37% to the total tax net in the last fiscal year.
However, the state spent Rs16 billion for the treatment of diseases directly related to tobacco use. Many lose the most productive years of life, families plunge into poverty, and the state has to divert resources away from development to treat tobacco-related morbidity.
Says activist Shanta Lall Mulmi: “Stronger regulation is necessary, but tobacco control is our collective responsibility. Everyone has to be involved in raising awareness if we want to make Nepal tobacco free by 2030.”
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