Implementation of MPOWER Package in the South-East Asia Region: Evidence from the WHO Report on the Global Tobacco Epidemic (2009-2021)

Setting the context In the WHO South-East Asia (SEA) Region, there are about 230 million adult smokers and 248 million adult smokeless tobacco users as per the third edition of the WHO Global Report on trends in prevalence of tobacco smoking (2000-2025). This makes the Region one of the largest consumers of tobacco, housing more than one fifth of all adult tobacco smokers and more than 80% of all adult smokeless tobacco users globally (WHO, 2019b). The WHO MPOWER package is a set of six evidence-based and cost-effective measures which was introduced on 7 February 2008 to facilitate the implementation of the provisions of the WHO Framework Convention on Tobacco Control at the ground level. These measures are: Monitoring tobacco use and prevention policies (M); Protecting people from tobacco smoke (P); Offering help to quit tobacco use (O); Warning about the dangers of tobacco (W); Enforcing bans on tobacco advertising, promotion and sponsorship (E); and Raising taxes on tobacco (R). Since its launch, the MPOWER package has become the guiding principle for all the Abstract

Countries of the Region have been striving to make incremental progress in the implementation of various provisions of the MPOWER package. Many of these measures are also the recommended "best buys" for effective tobacco control under the Global NCD Action Plan. The WHO Report on the Global Tobacco Epidemic (GTCR) is a biennial report that reviews the status of implementation of MPOWER measures around the world. Till now, eight GTCR reports have been published -from GTCR1 in 2008 to GTCR8 in 2021.
As per the third edition of the WHO Global Report on trends in prevalence of tobacco smoking , the prevalence of tobacco use in the SEA Region appears to be decreasing; however, the Region may just fall short of the target of a 30% relative reduction in prevalence between 2010 and 2025. As per the report, a gap of 0.5% still persists between the 2025 target prevalence (24.6%) and the 2025 projected prevalence (25.1%) of tobacco use by people aged >15 years in the Region (WHO, 2019b).
Thus, if the Region has to attain the global targets, it is imperative for the member countries to further strengthen their tobacco control efforts, including those aimed at more effective implementation of the WHO MPOWER package.
This review article tracks the implementation of the MPOWER measures in the 11 member countries of the SEA Region based on the last seven GTCR reports (GTCR2/2009-GTCR8/2021. This is with an aim to enable the countries to review their progress in implementing the MPOWER measures and to take steps to improve their advancement towards reducing the demand for tobacco products at the country level.

Monitoring tobacco use and prevention policies
Availability of recent, representative and periodic data on tobacco use for both adults and youth indicates the highest level of achievement in monitoring tobacco use and prevention policies. Currently, Bangladesh, Bhutan, Indonesia, Myanmar and Thailand are the countries of the Region at the best-practice level (WHO, 2021). Out of these, Bangladesh, Bhutan and Myanmar have exceptionally been retained in the best-practice group (based on their performance in GTCR 2019) in GTCR 2021 owing to the challenges of running national populationbased surveys during the COVID-19 pandemic (WHO, 2019a;WHO, 2021). In GTCR 2009, only one country (India) of the Region was in the best-practice group (WHO, 2009). In 2011, this increased to five countries (India, Indonesia, Myanmar, Sri Lanka and Thailand) (WHO, 2011). In 2013 and 2015, only two countries (India & Thailand and Nepal & Thailand, respectively) were at the highest level of achievement (WHO, 2013;WHO, 2015). In GTCR 2017, four countries (Bhutan, Indonesia, Myanmar and Thailand) were retained in the best-practice group (WHO, 2017). Notably, Thailand has been the most consistent in its performance. Please refer to Figure 1 and table 1 for details. DPR Korea, Maldives and Timor-Leste are the only countries in the Region that have never been at the highest level of achievement during the period 2009-2021. Additionally, in GTCR 2021, Indonesia and Nepal have been included in the countries that monitor Electronic nicotine delivery systems (ENDS) use in adults. Likewise, Thailand has been included among the countries that monitor ENDS use in adolescents (WHO, 2021).

Protecting people from tobacco smoke
As per GTCR 2017, 2019 and 2021, Nepal and Thailand are the only two countries in the Region that have all the public places completely smoke-free (WHO, 2017;WHO, 2019a;WHO, 2021). Additionally, as per GTCR 2021, Bhutan and DPR Korea need to cover only one more place (cafés, pubs & bars and government facilities, respectively) with a smoking ban to join the exclusive list of countries with comprehensive smoke free laws (WHO, 2021). In GTCR 2009, only one country (Bhutan) of the Region was in the best-practice group (WHO, 2009). In 2011, this increased to three countries (Bhutan, Maldives and Thailand) (WHO, 2011). In both 2013 and 2015, the same three countries (Bhutan, Nepal and Thailand) were at the highest level of achievement (WHO, 2013;WHO, 2015). Nepal and Thailand have been the most consistent in this category. Please refer to figure 2 and table 2 for details. India has one or more public places where designated smoking rooms are allowed. Separate, completely enclosed smoking rooms are only allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility. No reliable empirical evidence is presently available to ascertain whether they have been constructed (WHO, 2019a). Bangladesh, Indonesia, Maldives and Myanmar have only three to five public places completely smoke-free, and need to more holistically formulate and implement smokefree laws (WHO, 2021). Prioritizing availability and implementation of efficient and affordable tobacco cessation services ought to be the way forward for the Region. Tobacco cessation services, particularly those aimed at youth at the population level, need to be strengthened across the countries. Nicotine replacement therapy should be made available in the public health system. A national tobacco cessation strategy ought to be in place in all the countries. A national toll-free quitline number should be included in all tobacco control campaigns. Emerging technologies such as mTobaccoCessation should be leveraged. Quality counselling services and brief advice should be made available in school settings by training school health counselors and integrating the services with primary health

Offering help to quit tobacco use
In general, affordable tobacco cessation services are lacking in the Region (WHO, 2020). Exceptionally, India has strategically invested in scaling up tobacco cessation through mCessation services and the toll-free National Tobacco Quitline, which has four hubs servicing different regions of the country. The Quitline is staffed by 100 trained counselors providing services in over 15 languages to address the needs of 267 million adult tobacco users in India (WHO, 2021). In 2017, 2019 and 2021, India has been placed in the best practice group i.e., countries having a national quit line, and both NRT and some cessation services cost-covered (WHO, 2017;WHO, 2019a;WHO, 2021). Additionally, in 2013, Thailand was placed in this coveted list (WHO, 2013). Apart from India and Thailand, no other country in the Region has ever

Warning about the dangers of tobacco
The Region is performing progressively well in implementation of large graphic health warnings and is, in fact, one of the best performing WHO regions in doing so. Please refer to Figure 4 and Table 4 for details. With only one country (Thailand) in the best practice group (large warnings with all appropriate characteristics) in 2011, the Region has incrementally progressed and has as many as six countries (Bangladesh, India, Nepal, Sri Lanka, Thailand and Timor-Leste) in the elite group in 2021 (WHO, 2011;WHO, 2021). Besides, Thailand is one among the 17 countries of the world which had adopted legislation mandating plain packaging of tobacco products and had issued regulations with implementation dates (WHO, 2021). Maldives recently improved its legislation paving way for implementation of large and effective graphic health warnings. Myanmar is also implementing large graphic health warnings (WHO, 2018). Bhutan and DPR Korea have consistently lagged behind in implementing effective health warnings on packages of tobacco products and need to catch up. In mass media campaigns, Indonesia, Myanmar, Thailand and Timor-Leste are currently at the best practice level by conducting regular national anti-tobacco campaigns with at least seven appropriate characteristics including airing on television and/or radio (WHO, 2021). Please refer to

Raising taxes on tobacco
It is recommended to raise taxes to at least 75% of the retail price of the most widely sold brand of cigarettes. However, the countries of the Region have   been inconsistent in their efforts to raise tobacco taxes to the optimal level. It is imperative for the countries of the Region to raise taxes on all tobacco products, including smokeless tobacco products and indigenous smoking products, to decrease the demand for these products. In GTCR 2021, only Sri Lanka and Thailand have been placed in the best-practice group by levying taxes that comprise at least 75% of retail prices (77.02% in case of Sri Lanka and 78.6% in casFe of Thailand). In fact, globally, the most significant tax share increase during the period 2018-2020 was made by Sri Lanka, whose 2018 rate of 66.17% was raised to 77.02% by 2020 (WHO, 2021). In 2015 and 2017, only Bangladesh was in the elite group (WHO, 2015;WHO, 2017). In 2009In , 2011In and 2013, none of the countries in the Region could make it to the best-practice group (WHO, 2009;WHO, 2011;WHO, 2013). In 2019, Thailand was the only country in the Region that was in the best-practice category (WHO, 2019). Please refer to figure 7 and table 7 for details. Additionally, the Region is trying to leverage tobacco taxation revenue for funding tobacco control in the spirit of the Addis Ababa Action Agenda (Thai Health Promotion

Way forward
It is encouraging to note that the countries of the Region are progressively improving the implementation of MPOWER package in their jurisdictions. However, the momentum needs to be carried forward. DPR Korea, Maldives and Timor-Leste need to improve monitoring of tobacco use and prevention policies. Bangladesh, Indonesia, Maldives and Myanmar need to more holistically formulate and implement smokefree laws. The Region should prioritize availability and implementation of efficient and affordable quality tobacco cessation services, particularly those aimed at youth at the population level. Bhutan and DPR Korea have consistently lagged behind in implementing effective health warnings on packages of tobacco products. Bhutan, Maldives, Nepal and Sri Lanka ought to regularly conduct and sustain effective tobacco control mass media campaigns. DPR Korea and Indonesia should prioritize comprehensive TAPS ban for effectively tackling the tobacco epidemic. It is imperative for the countries of the Region to raise taxes, to at least 75% of the retail price of the most widely  sold brand, on all tobacco products, including smokeless tobacco products and indigenous smoking products such as bidi, cheroots or kreteks, to realistically decrease the demand for these products. The countries of the Region should look at taxing all forms of tobacco equitably. Despite making significant policy progress, the countries of the Region are falling short of the target of a 30% relative reduction in prevalence of tobacco use (between the years 2010 and 2025) by people aged >15 years (WHO, 2019b). Thus, effective implementation of tobacco control regulations and policies needs to be prioritized across the Region. Enhanced institutional capacity, operational effectiveness and political commitment at the country level could go a long way in improving enforcement of extant tobacco control laws. Dedicated well-structured National Tobacco Control Programmes with earmarked budgets and resources (as in India) can help transform policy progress into actual public health gains at the population level. Besides, lately, the dynamics of tobacco epidemic in the SEA Region seems to be changing. The tobacco industry is increasingly targeting the implementation of tobacco control measures. New tobacco products such as ENDS and heated tobacco products (HTPs) have emerged aimed at renormalizing   . The smokeless tobacco and areca nut are emerging as major stumbling blocks (Kaur, Thamarangsi and Rinkoo, 2017). Thus, it is important for the countries of the Region to be proactively vigilant about these emerging challenges. Also, supply side issues -addressing illicit trade in tobacco products, restricting access of tobacco products to minors and provisioning alternative livelihoods for tobacco growers and workers -are important for the Region. Unfortunately, as of now, only India and Sri Lanka are Parties to the Protocol to Eliminate Illicit Trade in Tobacco Products (WHO, 2020). Countries such as Bhutan, Maldives, Myanmar and Timor-Leste with porous international borders should immediately become Parties to the Protocol. Also, all the countries of the Region should effectively implement provisions related to restricting access of tobacco products to minors. Likewise, a lot of effort has gone into creating evidence on economically viable alternate crops to tobacco over a period of time. Various projects and programmes for alternative livelihoods to tobacco growing have been initiated in the Region, including in Bangladesh, India, Indonesia and Sri Lanka (Kaur, Rinkoo and Arora, 2014;WHO, 2020). However, the initiatives on provisioning viable alternative crop options for tobacco growers in these countries are generally limited to sporadic experiments carried out in research settings. A detailed plan of action at the field level needs to be drawn based on the recommendations of available research.