“Let Them Smoke Cigarettes: Smoking, Policy and Health for All”

The Nepali Government's commitment to providing "Health for All" by Year 2000 is a laudable aim. If there is one country that should be concerned about its citizens' health, it is Nepal. Its people are among the lowest per capita calorie consumers in the world; they have the lowest literacy rate and the lowest doctor to population ratio. The situation is even worse for poorer Nepalis, due to the dire imbalance of wealth and available resources. Kathmandu Valley, home to less than five per cent of the population, retains more than half of the country's doctors. Oddly, and most inappropriately, the Government itself is the main producer and pusher of a universally acknowledged health hazard, cigarettes. The Janakpur Cigarette Factory, which until recently had a virtual monopoly over cigarette production and is still, by far, the largest cigarette producer, is nationally owned. Its sizeable profits go directly into the national exchequer.

Alarming Addictions

Nepalis are addicted to tobacco in different ways: young, old, men, women and sometimes children barely out of infancy smoke bidis and hookahs, snort tobacco and chew khaini. But cigarette smoking has overtaken all these other addictions as a threat to Nepali public health, one that needs to be confronted by the Government and the public alike.

In the absence of comparable tobacco and health data for Nepal, the latest statistics from the United States can be used to help put things in perspective. More than 390,000 Americans die every year due to causes attributed to cigarette smoking. Thus, one out of every five deaths is related to smoking. It is responsible for 30 per cent of all cancer deaths, 21 per cent of all coronary heart disease deaths, 18 per cent of deaths due to stroke and 82 per cent of deaths due to chronic obstructive pulmonary diseases.

The pattern of smoking-related death and disease for Nepal may be different from that of the United States, but there is no doubt that many thousands of Nepalis die every year because they smoke, and also because of the interactive effect of smoking, grossly deficient diets, and unhygienic conditions such as improper ventilation.  While Americans are giving up cigarettes by the millions, smoking is an alarmingly accelerating trend among Nepalis. Worse still, Nepali cigarettes are much more hazardous than those available in the United States.

Smoke Pollution

Most Nepalis are exposed to cigarette smoke from childhood even if they do not smoke. Foetuses are affected in the womb when the expectant mother pulls on a cigarette. "Passive smokers" are children, office co-workers, fellow passengers, all non smokers who remain in enclosed spaces with others who smoke. Since there is no attempt to segregate smokers at home or in public spaces, passive smokers might as well start smoking for all the difference it makes. A child growing in a house with several smokers may suffer the same consequences as if he or she were a smoker. People who smoke are less efficient utilisers of nutrients. Smoking and malnutrition interact with infectious diseases, both chronic and acute, and leave a significant part of the population disease-ridden and lethargic.

There is indeed, no need to tell the Government about the dangers of smoking, both to the individual smoker, and to the overall health of the nation. For more than 20 years, anti-smoking campaigns in the United States have justifiably portrayed cigarette manufacturers as the enemy of the people, greedy and uncaring. The campaigns are comprehensive, encompassing research as well as public education. Scientific knowledge is used by policy makers and an informed public to change policies. Cigarette advertising, although well paying, is not carried by most newspapers, magazines and television stations.

Many governments in the west have active programmes to discourage smoking. A European anti-smoking conference held in Madrid last year, adopted a ten-point strategy to eliminate tobacco-related disease. The charter adopted by the conference emphasised fresh air, free from tobacco smoke, as "an essential component of the fundamental right of a healthy unpolluted environment for all." In Nepal, there seems to be no inclination to provide that fundamental right.

It is not that there has been a lack of rhetoric in Kathmandu. In 1984, a high-level conference was held here to discuss the ill effects of tobacco use. However, the sincerity of the authorities was more than undermined by a simultaneous announcement that the Government had given permission to open a privately-owned cigarette factory.

A major reason for governmental inaction must be that cigarette sales provide a major source of revenue. The Janakpur Cigarette Factory, biggest in Nepal and Government-owned to boot, is diversifying its output and getting more aggressive in its marketing. Janakpur remains the leading producer of cigarettes, but the Surya Tobacco Company, which started production in late 1986, has already taken 13 per cent of the market. National sales figures for the last five years show a death-dealing industry that is booming

And the Poor Get Sicker

While the Health Ministry obviously knows the scientific basis for discouraging smoking, the policies of the Government bespeak otherwise. The Government, as a matter of course, should be more concerned for the poor than for the rich, as the available data show that the poor are more at risk from Nepali cigarettes. The sales records of Janakpur and Surya Tobacco prove that even as the poor increasingly take to smoking, they are smoking the cheapest, lowest quality cigarettes that are most likely to give them disease.

The most popular cigarette of Janakpur is "Deurali," followed by "Gaida." Both are low-end, unfiltered products that make up 80 per cent of Janakpur's sales. Of the five brands produced by Surya Tobacco, there is only one brand without a filter. Yet, it is this unfiltered cigarette that constitutes 65 per cent of Surya's production. Those who can least afford to smoke and contract disease, are thus smoking the worst cigarettes. As someone said, "The poor get sick and the sick get poorer."

Smokescreens

Many arguments have been used over the years on behalf of Nepal's cigarette industry. One is the protectionist argument that cigarettes produced in Nepal keeps money inside the country, rather than enriching Indian or multinational tobacco giants. Another argument, less relevant now that there is domestic competition, is that Janakpur's profits go directly to the Government and are ultimately used for the "public good." Some go as far as to claim that cigarettes provide the only form of "escape" for much of the population, and so, "let them have their Gaidas and Deuralis."

These arguments are full of smoke. The Government should go out for a walk, take a deep breath of clean mountain air and look at its priorities straight in the eye. If the bottom line is people's health, then perhaps it should seriously consider a phased shutdown of the Janakpur Cigarette Factory. Also, it should make it more difficult for private entrepreneurs to start new factories.

Smoking vs. Alcoholism

Most Nepalis, while they take alcoholism seriously, treat smoking lackadaisically. Because of lack of education and information, they do not make the direct connection between smoking and ill health, the way they do between alcoholism and the destruction of self and family. The fact is that alcoholics are relatively few in number, but smokers are found in every office, every household. The lay person does not realise that the cigarette is an insidious killer. It has a grip on many more people, old and young, men and women alike, than alcohol ever will.

The Nepali population is not incapable of making sacrifices. Many would stop smoking and many more would not even start to smoke, if properly advised about the hazards of smoking. For their part, the policymakers in Kathmandu must look at ways to benefit the population in the long run, rather than making a few happy in the short run.

A Time for Cost Benefit

The Government must calculate the income it makes from pushing cigarettes and add up the millions spent in hospital care and doctors' bills for those who end up sick as a result of smoking. Even that calculation would be incomplete because it ignores large numbers of rural smokers who become disease-ridden or die, without the benefit of even a diagnosis of lung cancer, or other respiratory disease, much less a hospital care. The costs of Government-endorsed addiction, is thus, not entirely quantifiable in terms of rupees and paisas. And how much healthier the average Nepali would be if the resources squandered on smoking were used for a more nutritious diet?

If the goal of achieving Health for All by Year 2000 is serious, the authorities should start a massive public information campaign, to convince the people about the lethal dangers of smoking. But first, they must convince themselves. For, how can a government in this day and age, condone smoking and still speak about health for all with a straight face?

Shanta Dixit is an epidemiologist. She does not smoke.