The Impact of Cultural Pressures on Tobacco Harm Reduction Efforts in Southeast Asia

Provide clear education on the negative consequences of smoking and how it affects local communities, taking socioeconomic and cultural norms into consideration.

Make access to cigarettes and other more harmful tobacco products more difficult
(e.g., implement excise taxes), and manage attempts to circumvent tobacco control
actions (e.g., reducing access to illicitly sold tobacco products).

Offer a wide variety of safer nicotine products (e.g., ENDS, HnB, snus), and make
them readily available at a lower cost than cigarettes.

More than 8 million people die each year as the result of diseases associated with the overuse of combustible tobacco products, with the majority (80 percent) of deaths coming from lower- or middle-income regions of the world. In Southeast Asia alone, which is one of the largest areas of tobacco production and consumption, approximately 1.6 million lives are lost to smoking-related disease each year.

Tobacco harm reduction (THR) is a strategy that encourages those who choose not to quit or who are unable to quit smoking combustible cigarettes to use alternatives such as electronic nicotine delivery systems (ENDS), heat-not-burn (HnB) tobacco products and smokeless tobacco products. While not risk-free, these products have been shown to convey notably less risk (up to 95 percent less) than traditional combustible products, and THR experts believe that increasing access to and acceptance of these products could help mitigate the death and disease burden associated with cigarette smoking.

Many countries have adopted these types of programs successfully. In Sweden, for example, a combination of tobacco control approaches, education and a culturally accepted smoking replacement (snus—an oral tobacco product), have helped decrease smoking rates from over 20 percent in 2000 to less than 6 percent in 2021. Just this past year, the United Kingdom announced that it would be offering vaping starter kits to more than 1 million smokers to remove the cost barrier of switching to a lower-risk product and to help facilitate a complete transition from combustible cigarettes to reduced-risk e-cigarettes. In Japan, smoking rates dropped from 33 percent in 2000 to 20 percent in 2020, which some experts attribute to higher taxes, public smoking bans and the introduction of reduced-risk cigarette replacements such as HnB tobacco products. Importantly, the common thread among these approaches is that policymakers designed tobacco control and THR efforts to align with the values and preferences of their communities.

The World Health Organization (WHO) has also made efforts to reduce the tobacco-related disease and death burden. The organization’s Framework Convention on Tobacco Control (FCTC) was formed in 2005 and is primarily aimed at reducing the use of tobacco products. Thus far, 181 countries have signed this treaty, including many countries in the Southeast Asia region. Unfortunately, the FCTC’s efforts fall short because they attempt to apply universal tobacco control strategies to all countries and do not include THR strategies. The primary tools that the FCTC promotes globally include price increases (through taxes and other price-control measures), bans on tobacco-related communication (advertising, promotion, etc.), mandates for smoke-free spaces, requirements to include health warnings on packaging and attempts to interrupt illicit trade activities.

These efforts are not enough. This becomes especially apparent when looking at the Southeast Asian region of the world, where the measures that the FCTC promotes fail to align with individual countries’ needs—in large part because of the way tobacco is tied to that region’s political, cultural and financial circumstances.

To illustrate this point, we sought to evaluate the tobacco landscape in the Southeast Asian region of the world, focusing on three different countries where tobacco is a key aspect of the culture and economy: India, the Philippines and Indonesia. These three countries are particularly relevant in this assessment, as they are major producers and/or consumers of tobacco products and, interestingly, represent three distinct levels of involvement in FCTC tobacco control efforts: full adoption (India), partial adoption (The Philippines) and little/no adoption (Indonesia). For each of these countries, we review their tobacco production/use, tobacco control approaches (dictated in varying degrees by the FCTC) and implementation of THR strategies to illustrate the variety of culturally sensitive THR approaches being employed and how they influence public perception and health. As a result of this review, we conclude that a single approach to tobacco control and THR policy does not seem to yield the most effective outcomes for all countries. Instead, individualized, country-and-culture-specific approaches, built on key principles of THR, are needed.