1. Smokeless tobacco of Uzbekistan Nasway: PROCESSING: Sun- and heat-dried tobacco leaves, slaked lime, ash from tree bark, and flavoring and coloring agents are mixed together. Water is added and the mixture is rolled into balls

2. Smokeless tobacco is used in many regions of the world America –North America and Venezuela Europe- –Sweden, UK Asia – –Central Asia includes Nasway use –East and –Southeast Asia Middle-East – includes Nasway use –Iran, Saudi Arabia, and Arab countries Africa- Sudan

3. Short and Long Term Health Effects of Smokeless Tobacco Use Smokeless tobacco and cancer: –28 carcinogens have been identified in smokeless tobacco in the US. –Oral cancer, head and neck cancer, lung and pancreatic cancer Smokeless tobacco and hard and soft on-or pre- cancer oral lesions/conditions –Leukoplakia, other mucosal lesions, recession, gingivitis and periodontitis, dental caries, tooth abrasion/attrition

4. Nasway is as common as cigarettes among men in all age groups in Uzbekistan Source: Uzbekistan Health Examination Survey (UHES) 2002

5. Nasway is more common among elderly women in Uzbekistan Source: Uzbekistan Health Examination Survey (UHES) 2002

6. Smokeless is more common among the less educated: Evidence from Vietnam Source: Vietnam Living Standard Survey 1998

7. But, in Uzbekistan, except high education groups, men use nasway as much as cigarettes in all education levels Source: Uzbekistan Health Examination Survey (UHES) 2002

8. Smokeless is more common among the less educated women Vietnam Living Standard Survey, 1998

9. This is also the case in Uzbekistan. Source: Uzbekistan Health Examination Survey (UHES) 2002

10. As Income Increases, Smokeless Tobacco Use Declines, Cigarette Smoking Increases: An evidence from Vietnam Income Quintile Source: Vietnam Living Standard Survey 1998

11. Significant youth prevalence rate for smokeless tobacco in countries around the world Smokeless tobacco leads to smoking Source: GYTS 1999-2001 Ghana, Malawi Nigeria USA S. Africa Bahamas Zimbabwe Dominica 13-19 yrs old

12. Source: Guindon & Boisclair. 2003. WHO In the world today 48% of men 10% of women smoke

13. Unless current smokers quit, smoking deaths will rise dramatically over the next 50 years Source: Peto and others, 1994; Peto, personal communication.

14. Tobacco was the second leading risk factor for NCDs in Global Deaths in 2000 Deaths in 2000 attributable to selected leading risk factors Number of deaths (000s)

15. Mortality pattern in Uzbekistan, 2003 Ист: Комитет по статистике РУз Number of deaths are higher for diseases that tobacco use may be one of the major causes

16. Mortality due to cancer of lips, oral cavity and throat by age groups in Uzbekistan, 2003г. (in absolute numbers) Source: State Statistics Committee

17. Mortality by sex and age (%) Pattern of mortality due to cancer in Uzbekistan, 2003 ( %) Cancer of lips, oral cavity and throat Cancer of trachea, bronchi and lungs Source: State Statistics Committee, Uzbekistan Prevalence of cancer due to tobacco is 2 times higher in men

18. Tobacco attributable deaths The burden is moving to developing countries Source: WHR 2002 & Peto et al. 1997 v tobacco kills 4.9 million persons each year v half of them live in developing countries v the death toll is estimated to double in the 2020s v 70% of these deaths will occur in developing countries v 1 in 2 long term smokers die because of their addiction v half of all long-term smokers will be killed by tobacco and half of them will die prematurely, losing 20–25 years of life

19. Which interventions are effective? Measures to reduce demand Higher tobacco taxes Non-price measures: consumer information, research, bans on tobacco advertising and promotion, warning labels and restrictions on public smoking Increased access to nicotine replacement (NRT) and other cessation therapies

20. Youth are more sensitive to price/tax increases Tax elasticity of snuff in 1985 for: 16-25 yr old males -0.31 25+ yr old males -0.13 Ohsfeldt, Boyle 1994, Ohsfeldt, Boyle, Capiluto 1997 Tax elasticity of smokeless tobacco, 1992-94, for 8 th, 10 th, and 12 th grade students in US was -0.07 and -0.04 Chaloupka, Tauras, Grossman 1997

21. Adults are also sensitive to tax increases Tax elasticity : -0.15 –Snuff: -0.1 and –0.6 –Chewing: -0.13 and –0.6 Economic substitutes –Cross tax elasticity: 0.10 snuff- cig: 0.13 and 0.6 chewing-cig: 0.09 and 0.5 Source: Ohsfeldt and Boyle 1994, Ohsfeldt, Boyle, and Capilouto 1995

22. Very low price elasticity among youth and adults requires substantial increase in taxes to achieve a significant reduction

23. Effectiveness and Feasibility of Smokeless tobacco taxes Higher taxes work !! But: Are substantial tax increases politically feasible? –Yes! Given the relatively small share of tax in the price, a high tax increase would raise the prices a modest amount only. Could smokeless tobacco taxes be collected efficiently? Not certain that the cost of collecting taxes would be lower than the extra tax revenues.

24. Revenues for government and the industry are increasing despite reduction in consumption Source: The tax burden on tobacco 2000, FTC report to Congress 2001 Sales

25. Would other policies work? Yes! Raising minimum age from 18 to 19 would reduce probability of consumption by 25%. Strong licensing provisions would reduce the probability of consumption by 9% Ban on advertising could reduce consumption

26. Changing Advertising Pattern 1998 (mil US$) 1999 (mil. US$) % increase Newspapers2.83.318% Point of sale25.2264% Promotional allowances 14.930.7106% Coupons11.024.2121% All other5.97.322% Source: FTC Report to Congress 2001

27. Results Urgently need country-specific research evidence to tailor TC policies in Uzbekistan Smokeless epidemic already hit the poorest of the poor countries where TC action is weak. Comprehensive TC measures to reduce smoking work for reducing smokeless tobacco, w/o depending on tax increases alone. Strong measures should be taken to reduce youth prevalence and access to smokeless tobacco products.

28. Recommendations In countries where the smokeless tobacco already exist, protect youth from smokeless tobacco use by introducing comprehensive tobacco control measures Higher taxes supported by other tobacco control measures prevent youth to start using smokeless tobacco, but taxes should be increased substantially high to have significant reduction in smokeless tobacco demand. Although smokeless tobacco does not generate as much revenue as cigarettes, govt. will enjoy increasing revenues when taxes increase while consumption decreases.