Pakistan: Oral Nicotine Pouches in a LMIC

Pakistan is one of the largest tobaccoconsuming countries in the world. It is estimated that 25.4 million people (17%) currently use tobacco products in Pakistan, of which around 56% are cigarette adult smokers (9.6% smoking prevalence).^[1] The remaining 44% of the tobacco consumers in Pakistan predominantly use traditional oral tobacco-containing products such as Paan, Naswar and Gutka, which are known to typically have high levels of toxicants.^[2]

Thus, the opportunity for Tobacco Harm Reduction (THR) impact in Pakistan is significant. Pakistan has the 7th highest tobacco use globally. And with a significant proportion of that tobacco use being attributed to traditional oral tobacco-containing products often made in cottage industry,^[3] the introduction of lower risk profile Oral Nicotine Products could promote THR for Pakistan.

The health impact of Paan, Naswar and Gutka

Traditional oral-tobacco containing products, such as Paan, Naswar and Gutka, contain high levels of carcinogens such as heavy metals and tobacco-specific nitrosamines (TSNAs).[4-9] According to the World Health Organization's (WHO) 'Cancer Today' data, in 2022, Pakistan had the 4th highest lip and oral cavity cancer incidence rate, globally.^[10]

The high levels of toxicants in Paan, Naswar and Gutka contrast with Oral Tobacco Products such as snus,^[8,11] which in some countries have regulated limits for some toxicants.^[12] According to the WHO's data, oral cancer is the second most common in Pakistan and accounted for >8% of all cancer-related deaths in 2022.^[13] By contrast, Sweden, a country where Oral Tobacco Product use prevalence is twice as great as Pakistan (16% vs. 8%, respectively),^[14,15] has a lip and oral cavity age-standardised mortality rate** that is more than six times lower than Pakistan (1.3 vs. 8.6, respectively).^[16]

Not all oral tobacco products are the same

Due to the manner in which Paan, Naswar and Gutka are produced, comprehensive chemical analysis of their contents is sparse. However, of the data that is available, it is evident that these oral tobacco-containing products have higher levels of toxicants than Oral Tobacco Products, such as snus, and also much higher levels than are present in Oral Nicotine Pouches (Table 1).

Reducing tobacco consumption through tobacco control

Pakistan’s tobacco control initiatives have focused on tobacco taxation and price increases, to decrease tobacco consumption and deter people from starting tobacco use. In February 2023 alone, there was an approximately 150% increase in Federal Excise Duty (FED) on cigarettes, almost doubling the cost of a packet of cigarettes. A major problem in LMICs is the market for illegal cigarettes. More adult consumers are considering illicit tobacco due to increasing retail prices for legal cigarettes. As a result, the illicit trade in cigarettes is expected to grow significantly, shifting the demand from legal cigarettes instead of reducing overall consumption. This illicit trade results in poor quality unregulated products. It is estimated that over 50% of the market in Pakistan is illicit. The National University of Science and Technology (NUST), Islamabad, have reported an estimated illicit trade of approximately 63% of the total market.^[19] Lahore University of Management Science (LUMS) have reported an estimated illicit trade of approximately 58%.^[20]

Supporting THR through consumer choice

The role of Smokeless Products in THR for Pakistan is essential. Products such as Vapour Products and Oral Nicotine Pouches are lower risk profile alternatives to switch to for adult smokers and consumers of hazardous oral tobacco-containing products such as Paan, Naswar, and Gutka. Oral Nicotine Pouches are gaining popularity among adult tobacco consumers in Pakistan, as they are considered more hygienic and they do not produce as strong an odour as cigarettes, making them more socially acceptable. They are currently available at supermarkets and certain other retail shops.

Given the difference in risk profile between our Smokeless Products relative to these high-toxicant oral tobacco products used in Pakistan, we believe there is a tremendous Tobacco Harm Reduction opportunity for regulators. Providing information regarding the risk profile of our Smokeless Products and programmes that encourage complete switching to them could lead to significant declines in preventable oral cancer deaths over time.^[18,21,22]

A model for THR in LMICs

BAT subsidiary Pakistan Tobacco Company launched Velo brand Oral Nicotine Pouches in Pakistan at the end of 2019. Over the last five years, Velo grew in retail volume, in part because the regulation of these products in Pakistan allows us to connect with adult consumers and responsibly market these products to adult tobacco consumers. Pakistan has now become the largest consumer base for Oral Nicotine Pouches in the world and a role model for Smokeless Products in what the World Bank classes Low- and Middle-Income Countries (LMICs [countries with a gross national income per capita of $4,465 or less]***).

Velo is expected to develop and grow among adult tobacco consumers who do not wish to quit, supported by the introduction of new adult-orientated flavours in addition to its core flavours. The introduction of these new flavours that appeal to adult smokers may encourage more adult tobacco consumers, who do not wish to quit, to switch completely to Oral Nicotine Pouches.

A path forward

Our approach in Pakistan could accelerate THR in other LMICs. There will be challenges to overcome, including educating key stakeholders in our vision of A Better Tomorrow™ and encouraging adult smokers who would otherwise continue to smoke, and consumers of traditional oral tobaccocontaining products like Paan, Naswar and Gutka, to use alternatives. But taking Pakistan as a case study, we can see that there is a large, and growing, market opportunity for tobacco-free Oral Nicotine Pouches.