Comprehensive Review of Tobacco Control Measures in Sri Lanka: Insights from the WHO Report on the Global Tobacco Epidemic, 2023

This review article provides a comprehensive analysis of the tobacco control measures in Sri Lanka as outlined in the WHO Report on the Global Tobacco Epidemic, 2023: (1) Assessing the implementation and efficacy of the MPOWER measures, (2) monitoring tobacco use, (3) protecting people from tobacco smoke, (4) offering assistance to quit tobacco use, (5) warning about the dangers of tobacco, (6) enforcing bans on tobacco advertising, promotion, and sponsorship, and (7) raising taxes on tobacco. The review focuses on the current prevalence of tobacco use among adults and adolescents. The results emphasize notable advancements in the implementation of health warnings and advertising prohibitions. However, there are still obstacles to overcome in order to reduce the affordability of tobacco, enforce smoke-free policies in public spaces, and provide comprehensive cessation support. In addition to recommendations for strengthening tobacco control policies, the article concludes with further suggestions for the future development of Sri Lanka.

Introduction

Tobacco usage continues to be a significant global public health issue, leading to a considerable amount of illness and death. The World Health Organisation (WHO) reports that tobacco-related diseases cause more than 8 million deaths annually [1]. Tobacco use directly causes around 7 million deaths, while second-hand smoke exposes non-smokers to around 1.2 million [2]. Tobacco consumption is linked to several adverse health outcomes, encompassing chronic ailments, cardiovascular disorders, and respiratory illnesses [2].

In response to this global health crisis, the WHO has implemented numerous strategies to combat tobacco use, including the MPOWER measures. These measures are intended to facilitate the effective implementation of effective tobacco demand reduction interventions. Protecting individuals from tobacco smoke, Providing assistance to quit tobacco use, Warning about the dangers of tobacco, Enforcing prohibitions on tobacco advertising, promotion, and sponsorship, Monitoring tobacco use and prevention policies, and Raising tobacco taxes are all components of the MPOWER package [3].

This review aims to evaluate the effectiveness and execution of tobacco control strategies in Sri Lanka in line with the guidelines outlined in the WHO Report on the Global Tobacco Epidemic, 2023. The report is to provide a comprehensive overview of the current state of tobacco consumption in Sri Lanka, assess compliance with MPOWER measures, identify existing barriers, and propose improvements to tobacco control efforts. This review is to provide an academic contribution to the ongoing efforts to reduce the health impacts and prevalence of tobacco use in Sri Lanka.

Method

The data and conclusions presented in the WHO Report on the Global Tobacco Epidemic, 2023: Country Profile for Sri Lanka form the sole basis of this evaluation. The data from the report was systematically gathered, consolidated, and reviewed to assess the present condition of tobacco regulation initiatives in Sri Lanka. An assessment was conducted on the efficacy of the MPOWER measures by examining crucial metrics, including compliance scores and prevalence rates. The evaluation is predicated exclusively on the exhaustive data from the WHO report, without any gathering of primary data or statistical analysis.

Results

Overview of Tobacco Use in Sri Lanka

According to the WHO Report on the Global Tobacco Epidemic, 2023, tobacco use in Sri Lanka presents a mixed landscape (Table I). The Global Adult Tobacco Survey (GATS) 2019-2020 indicates that 19.4% of adults (36.2% of males and 4.9% of females) currently use tobacco [4]. This prevalence highlights the ongoing challenge of tobacco use in the country despite numerous control measures.

Table I. Tobacco Use Prevalence

Category	Current tobacco use (%)	Current smoking (%)	Daily smoking (%)
Adults (15+)
Male	36.2	19.7	13.9
Female	4.9	0.0	0.0
Both sexes	19.4	9.1	6.4
Adolescents (13–15)
Male	13.0	–	–
Female	3.1	–	–
Both sexes	8.1	–	–

MPOWER Measures in Sri Lanka

The MPOWER package comprises six evidence-based tobacco control methods that have been demonstrated to decrease tobacco usage and prevent loss of life effectively. The measures encompassed in this include the surveillance of tobacco consumption, safeguarding individuals from exposure to tobacco smoke, providing assistance for individuals to quit tobacco use, informing individuals about the hazards associated with tobacco, enforcing prohibitions on tobacco advertising, endorsing and supporting anti-tobacco initiatives, and increasing tobacco taxation.

Monitoring Tobacco Use

Sri Lanka has demonstrated a solid commitment to monitoring tobacco use. Nationally representative surveys of adults and adolescents are conducted periodically, providing essential data for public health interventions. The country scored 6 out of 10 in compliance, reflecting ongoing efforts but also indicating room for improvement (Table II).

Table II. Compliance Scores by MPOWER Measures

Measure	Compliance score
Monitoring	6
Smoke-free environments	6
Cessation programs	4
Health warnings	10
Advertising bans	6
Taxation	7

Protecting People from Tobacco Smoke

Sri Lanka has made significant strides in creating smoke-free environments. Complete smoke-free laws exist in several public places, including healthcare facilities, educational institutions, and government buildings. However, the absence of such laws in restaurants, cafés, pubs, and bars highlights a gap in the protection against second-hand smoke. The compliance score of 6 suggests a moderate level of enforcement (Table III).

Table III. Smoke-Free Environments Compliance

Public place	Compliance score
Healthcare facilities	10
Educational facilities	10
Government facilities	10
Indoor offices	10
Public transport	9
Restaurants, cafés, pubs, bars	0
Overall compliance	6

Offering Help to Quit Tobacco Use

In Sri Lanka, the support for quitting smoking is inadequate, as there is a lack of access to nicotine replacement therapy (NRT) and drugs such as Bupropion and Varenicline. While the establishment of a national quitline is a commendable advancement, there is a noticeable absence of comprehensive assistance in healthcare settings. This region requires substantial focus to offer sufficient assistance to persons seeking to cease tobacco use.

Warning About the Dangers of Tobacco

Tobacco packets in Sri Lanka have comprehensive health warnings that occupy 80% of both the front and back surfaces. The warnings are printed in the languages spoken in the area and contain visual representations that effectively communicate the risks associated with tobacco consumption. The country’s adherence to this domain is commendable; however, ongoing public education initiatives are imperative to reinforce these cautions.

Enforcing Bans on Tobacco Advertising, Promotion, and Sponsorship

Sri Lanka has enforced comprehensive restrictions on the advertising, marketing, and sponsorship of tobacco products, both directly and indirectly. This encompasses prohibitions on broadcasting through national television, radio, and print media, as well as restrictions on outdoor advertising. However, despite using these steps, ensuring compliance continues to be difficult, resulting in a compliance score of 6. Enhancing the effectiveness of enforcement procedures is essential to eradicate loopholes and guarantee adherence.

Raising Taxes on Tobacco

Implementing tobacco pricing is an effective strategy for decreasing tobacco consumption. The prevailing tax rate on the highest-selling cigarette brand in Sri Lanka amounts to 66.92% of the retail price (Table IV). Although the current share of taxes on tobacco goods is significant, there is room for future increases to make these products less cheap and discourage consumption (Tables V and VI). The level of affordability of cigarettes has remained relatively stable since 2020, suggesting the necessity for more assertive pricing measures.

Table IV. Price of Cigarettes and Taxation

Brand	Price (LKR) (for a pack of 20 cigarettes)
Lowest cost brand	300.00
Premium brand	1600.00
Total tax on most sold brand (%)	66.92
Affordability trend since 2020	No significant change

Table V. Supplementary Tax Information

Tobacco product	Total tax (%) (for a pack of 20 cigarettes)
Most sold brand of cigarettes	66.92
Cheapest brand of e-liquids	30.00

Table VI. Annual Tax Revenues from Tobacco Products

Year	Revenue (LKR billion)
2021	96.5
2022	102.3

Subnational Laws on Smoke-Free Environments

Subnational laws have also been enacted to ensure smoke-free environments, but the level of enforcement varies across different regions. Some areas exhibit robust compliance with smoke-free laws, while others lack effective enforcement mechanisms.

Regulation of ENDS and ENNDS

Electronic Nicotine Delivery Systems (ENDS) and Electronic Non-Nicotine Delivery Systems (ENNDS) are subject to the same regulations as conventional tobacco products. These items are subject to sales, advertising, and usage limitations to regulate their prevalence and safeguard public health.

Analysis of Compliance and Effectiveness

An evaluation of the efficacy of the MPOWER measures in Sri Lanka can be conducted by analyzing compliance scores and the temporal trends in tobacco consumption. Although there has been considerable improvement, significant deficiencies in some areas necessitate targeted interventions.

Challenges and Barriers

While Sri Lanka has made significant progress in implementing tobacco control measures, several challenges and barriers hinder further advancements:

1. Lack of Comprehensive Cessation Support: Limited availability of NRT and cessation medications reduces the effectiveness of cessation programs.

2. Incomplete Smoke-Free Legislation: Gaps in smoke-free laws, particularly in hospitality venues, undermine protection against second-hand smoke.

3. Enforcement Issues: Weak enforcement of advertising bans and smoke-free laws leads to non-compliance.

4. Economic and Social Factors: Affordability of tobacco products and cultural acceptance of tobacco use pose significant barriers.

Recommendations

To address the identified challenges and barriers, the following recommendations aim to strengthen the tobacco control measures of Sri Lanka and ensure more effective implementation of the MPOWER strategies:

1. Enhance Cessation Support: Expand the availability of NRT and cessation medications and integrate cessation support into primary healthcare facilities.

2. Strengthen Smoke-Free Laws: Extend complete smoke-free laws to all public places, including restaurants, cafés, pubs, and bars.

3. Increase Tobacco Taxes: Implement higher taxes on all tobacco products to reduce affordability and consumption.

4. Continuous Public Education: Conduct ongoing mass media campaigns to educate the public about the dangers of tobacco use and the benefits of quitting.

5. Improve Enforcement: Strengthen existing tobacco control laws to ensure full compliance and address gaps in the current regulatory framework.

Suggestions

To complement the recommendations and further enhance tobacco control efforts in Sri Lanka, the following suggestions focus on preventive strategies and community engagement:

1. Introduce Comprehensive School-Based Education Programs: Implement tobacco education programs in schools to target adolescents and prevent the initiation of tobacco use.

2. Promote Smoke-Free Homes: Encourage smoke-free policies in homes to protect children and non-smokers from second-hand smoke.

3. Leverage Technology for Cessation Support: Develop and promote mobile apps and online resources for tobacco cessation support.

4. Engage Community Leaders: Involve community leaders and influencers in anti-tobacco campaigns to enhance their reach and impact.

5. Conduct Regular Evaluations: Perform regular evaluations of tobacco control policies and programs to assess their effectiveness and make necessary adjustments.

Conclusion

Sri Lanka has made significant strides in adopting tobacco control measures, particularly in the areas of monitoring tobacco usage, issuing health warnings, and enforcing advertising bans. However, there are still deficiencies in the provision of assistance for quitting smoking, ensuring that individuals are protected from tobacco smoke in all public areas, and implementing tax increases to make nicotine less affordable. To further decrease tobacco use and its related harms in Sri Lanka, it is essential to address these gaps by implementing more robust legislation, enhancing enforcement, and implementing comprehensive public health interventions.