Prof. Dr. Shyam P Lohani

About 1.1 billion world populations are smokers today. If this trend continues, there would be an estimated 1.6 billion current tobacco smokers by 2025 (The Lancet, 2015) of which 80 per cent live in low and middle-income countries. The amount of investment for the treatment of tobacco-related diseases outweighs the revenue it generates for most of the countries in the world. It has been estimated that a significant proportion of the monthly household income is spent on tobacco and tobacco-related products and more so among poor families in developing economies. Therefore, tobacco use contributes to poverty by diverting household income from basic needs to tobacco.

Situation
The global cigarette market in 2018 worth US$ 888 billion and expected to reach US$ 1,124 billion by 2024 (Cision, 2019). Around 12 billion cigarette sticks are consumed in the country and per capita consumption is 420 sticks which are far less than the highest consumption per capita in Japan i.e. 1,841 sticks. It has been estimated that about 3 per cent of the total revenues of the Government of Nepal was contributed by the single largest manufacturer of cigarettes in 2017 and only about 4.7 per cent of total revenues from tobacco-related products.
The recent STEPS survey report showed 28.9 per cent of the populations are currently using tobacco in Nepal and more than four times among males than females (NHRC, 2019). The average age of initiating smoking among those who smoke daily was 17.8 years; however, many studies have reported that the actual age of initiating tobacco among Nepali youths was quite earlier than the initiation of smoking. In Nepal, about 27,000 deaths are attributed to tobacco-related diseases which accounts for 14.9 per cent of all deaths (WHO Fact Sheet, 2018). The most common way of tobacco-related deaths is due to cardiovascular diseases (CVDs) followed by chronic respiratory diseases.
There are more than 7000 chemicals present in tobacco smoke of which more than 250 are harmful to human health and among them, about 70 are known carcinogens. There is no single safe and beneficial chemical in any of the tobacco-related products. The chemicals present in tobacco affect our entire body and there is almost no organ that is spared by the harmful effects of tobacco. According to WHO (2019), tobacco kills up to half of its users by tobacco-related diseases. On average, smokers die 10 years earlier than non-smokers reports CDC (2018). Nicotine is the mood-altering chemical present in tobacco which reaches the brain in seconds following smoking and causes the transient feeling of more energised for a while but as its effect wears off, a smoker feels tired and craves for more.
Smokers tend to have more infections besides chronic nonreversible respiratory conditions such as emphysema, chronic bronchitis, COPD and lung cancer. Children whose parents are smokers are more prone to coughing, wheezing and asthma attacks than children whose parents do not smoke and they are also more likely to have bronchitis and pneumonia (Healthline, 2017). Smoking damages the entire cardiovascular system in humans. Nicotine tightens the blood vessels restricting blood flow which can cause peripheral artery disease. An increase in blood pressure, weakening of walls of blood vessels and an increase in clot formation due to smoking may result in raising chances of stroke. People who have already gone through bypass surgery had a heart attack or stent on blood vessels are more prone to the adverse effects of smoking.
Smoking raises the risk of mouth, throat, and larynx and esophagus cancer. Smokers are also at higher risk of pancreatic cancer than non-smokers. Other cancers such as kidney, liver, colon, and cervical cancers are also increased among smokers. Smoking causes insulin resistance and thus there is an increased risk of type 2 diabetes among smokers. Nicotine causes a decrease in blood flow to the reproductive organs and therefore causes a decrease in sexual performance among male and sexual satisfaction among women resulting in to decrease in sexual desire among both sexes. Smoking increases the risk of ectopic pregnancy, reduces the baby’s body weight, increases the risk of preterm delivery, damages the fetus’s lung, brain, and CNS, increases the chances of infant sudden death syndrome and contributes to congenital abnormalities such as cleft lip or cleft palate. Poor oral hygiene and unhealthy skin and hair are other effects of smoking.
Nepal government of Nepal has taken up several tobacco control measures. Government has formulated directives to the manufacturer which was effective from 15 May 2015 that they should print or mark clearly understandable and visible warning message including consumption of tobacco product is injurious to health in Nepali Language and graphic health warning covering at least 90 per cent of total outer portion of the box, wrappers, packet and packaging and label of tobacco product. This directive has not yet fully complied with by the manufacturer.

Burden
This will raise much-needed funds for promotive, curative as well as rehabilitative aspects of tobacco-related burdens to the country. The policy directives such a restriction of sales of tobacco products to certain age groups and ban on tobacco advertisement in TV and print media may contribute to decreasing prevalence of tobacco use in the country. The decrease in the affordability of tobacco products may reduce the prevalence of tobacco consumption. World Health Organisation recommends at least 70 per cent excise on tobacco products whereas Nepal taxes only about 30 per cent which is one of the lowest in the region.
The good news is most of the adverse effects of tobacco products can be prevented and also reversed. The strong control measures for preventing youth from initiating the use of tobacco, initiating tobacco cessation at the health institutions and nicotine replacement therapy, and youth-led anti-tobacco campaigning are much-needed programs to reduce tobacco use in the coming days.

(Prof. Lohani is the Founder and Academic Director of Nobel College and Hospital and can be reached at lohanis@gmail.com)