06 Apr 2018
Topics Health

Can a health systems ‘scorecard’ help ASEAN countries kick the smoking habit?


In light of World Health Day, we explore how ASEAN nations are managing the tobacco epidemic.

A health systems 'scorecard' has been created to assess the tobacco control capacity of ASEAN nations. Can it help address the high number of smoking-related deaths in the region?

Nothing illustrates the divide between ASEAN nations more clearly than how they deal with the public health issue of smoking. While Singapore recently tabled a new bill to raise the minimum smoking age from 18 to 21, Indonesia sits on the other end of the spectrum, with 3.9 million children between the age of 10 and 14 joining the legion of 60 million smokers in the country every year.

Can a health systems scorecard' help ASEAN countries kick the smoking habit?



On the whole, more than half a million people from the low and middle-income countries of ASEAN die every year from tobacco-related causes. This translates to a higher than average rate of death from tobacco-attributable cause in ASEAN (10%) compared to the rest of the world (8.6%)[i].

Despite this alarming statistic and the establishment of the Framework Convention on Tobacco Control (FCTC) by the World Health Organisation (WHO) more than a decade ago to help combat the smoking epidemic, ASEAN nations continue to face various challenges that exacerbate inertia in tobacco control policymaking, a fact laid bare by researchers Gianna Gayle Herrera Amul and Visiting Professor Dr Tikki Pang of the Lee Kuan Yew School of Public Policy in a recent study.

For the study, the researchers created a scorecard that referenced the FCTC to illuminate gaps in tobacco control in ASEAN countries, from laws regulating smoking to availability of cessation support. Sorting the checklist of indicators into categories such as leadership and governance also helped pinpoint where the major issues lie for each country.


The countries that stood out

Indonesia was the poorest performer out of the 10 ASEAN countries assessed with a score of 34.5. Most glaring was the country's lack of top-down tobacco supply control measures. By far, leadership and governance has the biggest determining role in whether the other building blocks of tobacco control, such as human resources and financing, are present or functioning, says Prof Tikki.

The reason behind Indonesia's profound inadequacy at the highest level is Big Tobacco's chokehold on the national economy. Tobacco companies make up 30% of Indonesia's economy, he explains. Moreover, the minister of health is always in a much weaker political position compared to the minister of finance, minister of trade and minister of agriculture, so the Indonesia example highlights a very complicated issue [in tobacco control].

Meanwhile Thailand, often lauded for its comprehensive and often creative measures in reducing smoking prevalence, stood out as one of the highest-ranked countries on the scorecard. In addition to influential grassroot initiatives supported by the government, Thailand has a successful universal health coverage system that has been widely referenced in research, says co-researcher Amul. Reflected in the scorecard, the country is the only one in ASEAN to offer fully-subsidised nicotine replacement therapy as a form of demand-reducing tobacco control.

Scoring highly alongside Thailand for its efforts to provide readily available smoking cessation support is Singapore, whose smoking prevalence of adult males is the lowest in the region. According to the details of the scorecard, Singapore can attribute a large part of its success to its governance: it is the only ASEAN country to have an enforced written policy or code of conduct across all government ministries to prevent tobacco industry interference.

However, the scorecard also hints at a unique set of challenges for the city-state. Despite being the country in ASEAN with the most human resources allocated to tobacco control, the smoking prevalence of adult males is slowly rising. In fact, it is the only ASEAN country to consistently exhibit an upward trend in adult male smokers in the past 15 years. At current rates, the WHO projects that Singapore will have a higher percentage of smokers than Myanmar in their respective populations by 2020.

For Singapore, the trend may signal a need for local authorities to review the country's strategic approach to tobacco control measures. In particular, the researchers noted that Singapore has the opportunity to get more value out of its efforts (i.e. how to effect a greater reduction in smoking with every government dollar spent) possibly by taking a leaf out of Thailand's book.


Dealing with smoke and mirrors

Although the scorecard has helped put tobacco control efforts of countries in the region into perspective, the researchers note that effecting positive change on a national level ultimately relies on political will.

As a political association of nations, ASEAN should be held accountable for not setting a rigorous agenda on tobacco control. The main challenge we recognised [from the study] is how to push governments to implement more effective tobacco control policies, says Prof Tikki. Moving forward, you have to ask, Where is the political leadership at the ASEAN level and the commitment on the part of governments to be more forceful about this?'

To achieve action is to, first and foremost, change the way the association works. ASEAN has a fundamental weakness in the way it operates, in which agreements are solely made by consensus and not by vote. In situations like this [tobacco control] where it is an urgent public health issue, maybe this is not the best system of decision-making, the professor adds.

Even with the presence of government support, countries still need to address gaps in tobacco control implementation. If you have quit lines but not the facilities to give support for tobacco cessation, there's no point, says Amul. The idea of this framework, this scorecard, is also to convey that measures need to work holistically, so they can help smokers who want to quit follow through, which often is the hardest part.


The path ahead

Meanwhile, for researchers, this scorecard represents a good starting and reference point for further research. We have a desire that specific components of this [scorecard] can actually become a study in and of itself, says Prof Tikki. For instance, the scorecard can be expanded. It may make sense to link indicators to outcome measures within countries, as long as we are able to obtain the data and, if possible, use modelling approaches on the data.

Aside from academia, the researchers also welcome the input of non-governmental organisations (NGOs) involved in anti-tobacco programmes in the region. The professor says, The type of data gathered can also be expanded to include field survey data by NGOs, for example. Varied input from different sources may help improve the scorecard's accuracy and provide more nuanced insight, such as whether a smoking regulation is effectively enforced.

The researchers also note that, as further research on tobacco control is carried out and new evidence emerges, individual indicators may also be added, amended or refined to keep the scorecard up to date or increase its utility. For example, Singapore authorities are mulling over a hybrid, evidence-based measure to increase the coverage of health warnings on tobacco product packaging while also introducing plain packaging on these products[ii]. If these measures are implemented and proven to effect the desired outcomes, then the scorecard should adapt and change, the researchers acknowledge.

If the scorecard approach is able to inform research into specific aspects of tobacco control, this study would have fulfilled part of its purpose. On the other hand, the proverbial elephant in the room remains: will ASEAN political leaders sit up and take notice of a scorecard that could give their countries a chance to tacitly address one another's relative strength and weakness in tobacco control? Will they progress to engaging in transfers of knowledge and resources needed to improve health systems and fight an urgent health issue?

Whether a scorecard can kick-start a new era of smoke-free diplomacy, only time will tell.

Access the full study here: http://onlinelibrary.wiley.com/doi/10.1002/app5.218/pdf

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[i] http://www.prb.org/pdf15/2015-world-population-data-sheet_eng.pdf (2015 figures)

[ii] http://www.straitstimes.com/singapore/health/moh-seeks-public-feedback-on-standardised-tobacco-packaging-with-bigger-graphic

Topics Health