Tobacco control policies and the health of Adolescents in Pakistan (TAP): a multi-method study

Globally, tobacco is responsible for over 8 million deaths each year. Most people start using tobacco during adolescence. Doing so increases their chances of developing health problems, such as asthma, and continuing to do so into adulthood increases their risk of cancers, cardiovascular and respiratory problems, and premature death. Therefore, preventing tobacco uptake is a public health priority. Robust policies have resulted in a steep decline in youth uptake in high-income countries. However, most low and middle-income countries (LMIC) lag behind. For example, one in 10 adolescents use tobacco in Pakistan compared to one in 40 in the UK. Such differences highlight a lack of robust policies to protect adolescents from cheap tobacco and aggressive tobacco industry marketing.

Pakistan is heavily burdened by tobacco-related diseases, with over 160,000 tobacco deaths per year, yet it is one of the world's cheapest and most unregulated tobacco markets. Pakistan's government has reinvigorated its commitment to fulfil its obligation to protect adolescents from tobacco. A tobacco control policy roadmap includes plans to raise taxes and introduce plain packaging. Following a request from Pakistan's National Tobacco Control Cell, established by the government to enhance tobacco control efforts in Pakistan, we propose a research programme that aims to inform plain packaging policy and future tax reforms in order to reduce tobacco uptake and use among adolescents.

Based on established methods in policy research, we will conduct five complementary studies. For the first three studies we will: conduct a pack collection exercise to explore how the packaging is being used to promote tobacco products, and to assess compliance with current health warning regulations (Study 1); interview those who advise, inform, legislate and advocate for tobacco control policies to gauge their level of support for and views on plain packaging and tax rises (Study 2); and explore adolescent's exposure to, and perceptions of, tobacco packaging, and response to plain packaging, and tobacco prices in focus group discussions (Study 3). For Study 3, to ensure the inclusion of adolescents who attend school and adolescents who do not, a significant issue in Pakistan, we will conduct eight focus groups with school attenders and eight with those out of school.

Building on the earlier studies, in Study 4 we will conduct a survey with adolescents aged 10-16 years-old. We aim to recruit 5,670 in secondary schools and 2,880 in community settings. We will collect data on tobacco-related attitudes and behaviours. We will also assess perceptions of a range of tobacco packs on sale in Pakistan, and response to the health warnings that are on packs, and to plain packaging. Data on tobacco purchase behaviours, including product substitution and brand switching, will be collected. In addition to collecting data that will be crucial for informing policies, the survey will also provide a baseline for the future evaluation of any regulations and tax reforms. In parallel with the survey, in Study 5 we will estimate the predicted fall in tobacco use in adolescents as a result of a tobacco price increase to inform tobacco tax policies in Pakistan.

To deliver this work, our team includes epidemiologists, statisticians, clinicians, health economists, behavioural and political scientists. Our expertise is in policy research, tobacco control, research translation, capacity strengthening and leading research consortia. In addition to the Ministry of Health, we are partnering with civil society advocates, clinicians, academics and legislators through a policy forum and with adolescents through youth advisory panels. With the help of our stakeholders and dissemination channels, we plan to inform tobacco control policies in Pakistan and beyond. By helping to prevent uptake among youth, our research will contribute to reducing the tobacco-related disease burden in LMIC.

Tobacco kills over 8 million people per year. Most tobacco users start during adolescence, and many continue into adulthood. Tobacco use among youth is declining in high-income countries, with most low and middle-income countries lagging behind, highlighting the need for robust policies. Pakistan has one of the world's highest tobacco-related disease burdens. Pakistan's government is committed to raising tobacco taxes and introducing plain packaging. We aim to inform these policies in Pakistan in order to reduce tobacco uptake and use among adolescents, thereby improving their health and preventing premature deaths and disabilities in later life.

We propose a multi-method design, with five complementary studies: 1) A tobacco pack analysis will assess how tobacco companies promote their products, and compliance with warning regulations; 2) Stakeholders' interviews to ascertain support for, and views of, both policies; 3) Focus groups with adolescents to explore perceptions of tobacco packaging, including plain packaging, and prices; 4) A large cross-sectional survey with 10-16 year olds, including those attending secondary schools, and those in community settings who are not attending school, will explore their tobacco-related attitudes and behaviours, perceptions of tobacco packs and tobacco purchase behaviours; and 5) A price elasticity study to estimate the predicted fall in tobacco use in adolescents following a tobacco price increase.

Our multidisciplinary team has expertise in tobacco control, policy evaluation and research translation. With our extensive policy links, we are confident that our work will directly contribute to improving adolescent health in Pakistan and beyond.