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 adulthoodincreases their risk of cancers, cardiovascular and respiratory problems, and premature death. Therefore, preventingtobacco uptake is a public health priority. Robust policies have resulted in a steep decline in youth uptake in high-incomecountries. However, most low and middle-income countries (LMIC) lag behind. For example, one in 10 adolescents usetobacco in Pakistan compared to one in 40 in the UK. Such differences highlight a lack of robust policies to protectadolescents 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 theworld's cheapest and most unregulated tobacco markets. Pakistan's government has reinvigorated its commitment to fulfilits obligation to protect adolescents from tobacco. A tobacco control policy roadmap includes plans to raise taxes andintroduce plain packaging. Following a request from Pakistan's National Tobacco Control Cell, established by thegovernment to enhance tobacco control efforts in Pakistan, we propose a research programme that aims to inform plainpackaging 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 studieswe will: conduct a pack collection exercise to explore how the packaging is being used to promote tobacco products, and toassess compliance with current health warning regulations (Study 1); interview those who advise, inform, legislate andadvocate for tobacco control policies to gauge their level of support for and views on plain packaging and tax rises (Study2); 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 schooland adolescents who do not, a significant issue in Pakistan, we will conduct eight focus groups with school attenders andeight 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 torecruit 5,670 in secondary schools and 2,880 in community settings. We will collect data on tobacco-related attitudes andbehaviours. We will also assess perceptions of a range of tobacco packs on sale in Pakistan, and response to the healthwarnings that are on packs, and to plain packaging. Data on tobacco purchase behaviours, including product substitutionand brand switching, will be collected. In addition to collecting data that will be crucial for informing policies, the survey willalso provide a baseline for the future evaluation of any regulations and tax reforms. In parallel with the survey, in Study 5we will estimate the predicted fall in tobacco use in adolescents as a result of a tobacco price increase to inform tobaccotax policies in Pakistan.To deliver this work, our team includes epidemiologists, statisticians, clinicians, health economists, behavioural and politicalscientists. Our expertise is in policy research, tobacco control, research translation, capacity strengthening and leadingresearch 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 ourstakeholders and dissemination channels, we plan to inform tobacco control policies in Pakistan and beyond. By helping toprevent uptake among youth, our research will contribute to reducing the tobacco-related disease burden in LMIC.