Tobacco Policies And Regulations In Cambodia

Tobacco use has a direct link with the significantly increased risk of getting Chronic Obstructive Pulmonary Disease (COPD) as well as other lung and heart diseases, affecting both smokers and non-smokers alike (REF). COPD, in particular, is currently the eighth leading cause of death amongst the citizens of Cambodia (REF). According to the Institute of Health Metrics and Evaluation (IHME), Cambodia’s mortality rates for COPD in 2016 had increased by over one third since 2005. In 2008 the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) introduced the MPOWER package, designed to assist countries in creating tobacco control and reduction policies. The WHO FCTC covers almost 90% of the world with a legally binding treaty, which aims to reduce tobacco use by 30% in each country by 2025.

Currently, Cambodia is not on track to reach this target. With the introduction of higher taxes on tobacco as well as increasing education, restrictions and controls on tobacco and cigarette packaging, the Royal Government of Cambodian (RGC) will not only increase the possibility of meeting the WHO FCTC goal, but will also see a change in quality of life and financial gain, as well as potentially better healthcare options amongst the low-income community of Cambodia. Purpose Despite efforts from the RGC by enforcing public smoking bans in 2016, the country still holds one of the highest tobacco smoking rates in the world. Tobacco use has been titled as the third highest risk factor for death and disability for Cambodians and globally, tobacco use is linked to roughly 6 million deaths per year, with most occurring in middle to low-income countries. The purpose of this brief is to discuss a number of reachable goals and recommendations that will benefit both the Cambodian public and the RCG. These recommendations involve the implementation of certain tobacco taxes, packaging controls, and offering guides, information and education regarding personal tobacco regulation. Through the application of recommendations, the RCG will increase the probability of completing the United Nations 2030 sustainable development goal of eradicating extreme poverty, reducing the age of standardized death rates from non-communicable disease by 30%, and attain universal health coverage.

Tobacco tax

It has been shown time and time again that raising tobacco taxes is the most effective way to decrease the number of smokers in low-income regions. According to WHO, Cambodia currently has a 25% tax on the most popular cigarette brand with only 13% of that tax coming from ad valorem excise. WHO recommends that there is at least 70% excise (both ad valorem and specific) tax share in the final retail price. This increase has the aim to make cigarettes less affordable to the public and increasing revenue for the government. Annually 100 million people fall into poverty, largely due to out-of-pocket expenditures from non-communicable disease treatment (WHO). A poverty analysis conducted by the Asian Development Bank in 2014 found that those living in struggling conditions were less likely to eat healthily and more likely to smoke. From the results of a Cantril Self-Anchoring Striving Scale Poll conducted in Cambodia, 63% of respondents implied that they were struggling, and therefore at the greatest risk of being current or future smokers. The majority of individuals in this group were also members of the lower-income quartile of Cambodian citizens. Whilst tobacco remains as such an affordable product the chances of smoking is significantly increased amongst the disadvantaged, increasing the risk of non-communicable disease and treatment, and thus increasing the chance of poverty.

Second Hand Smoking Effects and Awareness

The banning of smoking and blowing of tobacco products in 2016 brought a large restriction on where tobacco smoking was permitted, making workplaces and many public areas off limits. However, this does not apply to private residencies and vehicles. As it is impossible for any government to regulate what one does in their own home, it is important that smokers are given the right information and tools in order to understand how tobacco smoke affects their households and families. One major consequent of smoking is “the side stream smoke coming from the burning tip of a cigarette and exhaled mainstream smoke”. This is better known as second hand smoke (SHS) and can lead to the involuntary smoking of individuals in the vicinity of a lit cigarette. SHS is estimated to contribute to 10% of tobacco-related mortalities annually. A recent study in Poland found that 40% of surveyed students were exposed to SHS in their own home on a daily basis. As well as examining the exposure rate for students from socially disadvantaged rural areas of Poland, the study also assessed the awareness of SHS and its negative health effects. With this, the study concluded that 70% of students understood the risks from SHS and the majority believed that smoking in the home should be banned yet were still faced with daily exposure in their private residencies. Although this study was undertaken in Poland, it can be estimated that Cambodia would display similar, if not, more negative results, with the majority of households being from urban or rurally disadvantaged areas. Whilst most students are being educated about the consequences of voluntary and involuntary smoking in school programs, UNICEF shows that less than 46% of the adolescents in Cambodia are taking part in secondary school allowing for the assumption that awareness of smoking and SHS risks would be much lower than those of Poland, where more than 90% of its young citizens are enrolled in secondary school. Along with this gap in education among adolescents not enrolled in school, there is also a gap in tobacco education for adults and parents. Statistics show that over 2 million adults were classified as illiterate in Cambodia in 2015. A study on the awareness of SHS risks in China found that the lower the respondents educational level, the lower their understanding of the effects of SHS.

Tobacco packaging regulation

At present, the RGC has no laws or requirements for health warnings on packaging to not be concealed in any way, allowing the manufacturer to cover warnings with stamps, images and other obstructive mechanisms. Whilst the law does prohibit the use of misleading or misdirecting terms such as “mild” or “low tar” on packaging, the manufacturer is still free to print figurative signs, such as colors, numbers and images that imply those prohibited misleading terms. In 1954, Louis Cheskin, a psychologist, conducted research that explored how color affected the purchasing choices of consumers. He concluded that the consumer unconsciously transferred the sensations from color and design to the sensation of taste. Tobacco companies have not only followed and applied Cheskin’s work but have also employed him as a consultant of packaging redesign (PCR), proving that manipulation of the consumer has always been a key strategy in cigarette marketing. These enticing marketing and eye-catching packaging strategies can be controlled through the passing of one simple legislation mandating plain packaging on tobacco products. Despite tobacco companies arguing that plain packaging will only stop consumers from switching brands, a number of countries have already passed the legislation. Australia was the first country to implement plain packaging in 2012 and has already seen a decrease in continued and new smokers, with 17 countries following suit. The plain packaging also requires that health warnings make up over 80% of the packages display. This is compared to Cambodia, which requires that only 55% of packages have health warnings, which also can be obscured by stamps, stickers and other obstructions. Recommendations Tobacco tax WHO states that cigarettes are still as affordable as they were in 2014, making smoking a very readily available ‘hobby’. It is also evident that the increase of taxes effects those with low-income and the youth, with “price responsiveness… twice as great as it is for older people and smokers on a high income”.

A study recently conducted by the Global Tobacco Economics Consortium found that by simply increasing the price of tobacco by 50% in low to middle-income countries, the bottom income group would have 7.7 times as many quitters in comparison to the top income group. It is recommended that a combination of ad valorem and specific excises are put into place at a total of 70% of the retail price. This will deter many people from continuing or beginning to smoke. Not only would a tax increase affect the number of life years gained by those who give up smoking, but an increased tax revenue can be used on implementing and maintaining health care, and other social services for people on a low income. Most impressively, the decline in out-of-pocket expenditures from requiring treatment for tobacco-related diseases will also decrease the number of citizens living in or falling into poverty.

The packaging and labeling color of cigarettes should be treated as equally as important as the ingredients of the product. Tobacco companies are able to evade laws that control and prevent them from including manipulative marketing through the color and design of the packaging. An analysis conducted in 2017 found that tobacco companies have long used color depictions to communicate brand imagery, blanket health concerns and portray prohibited words such as ‘strong’ or ‘smooth’. In 2011, Australia implemented the Tobacco Plain Packaging Act (TPP) in order to regulate tobacco packaging and appearance. The TPP Act listed that the improvement of public health and to meet obligations in the Convention on Tobacco Control were its main goals. These two goals should be applied to the RCG. By requiring that all packaging and display share the exact same design and color, consumers are not manipulated or diverted into misleading mindsets. Furthermore, the RGC needs to increase the number of approved health warnings displayed on packaging, incorporating more graphic health warnings and including the effects of SHS on adults and adolescents. It is not impossible for Cambodia to claim a spot in the world’s leading countries in tobacco control. Through proper regulation of tax excising, improvement in SHS educational guides and the application of plain packaging and increased health warning laws, the RGC can expect results in a number of areas; improvement of overall public health; decrease in current and new smokers; decrease in out-of-pocket expenditures; increase in tax revenue; and an increase if quality of life. All of these results can further contribute to Cambodia’s input in the WHO FCTC goal of decreasing the use of tobacco by one third by 2025.