Tobacco Control Issue: Review Article
Challenges of smokeless tobacco use in Myanmar Sein T, Swe T, Toe MM1, Zaw KK2, Sein TO People’s Health Foundation, 1Department of Medical Research (Central Myanmar), Nay Pyi Taw, Myanmar, 2Department of Medical Research (Lower Myanmar), Yangon Correspondence to: Dr. Than Sein, E‑mail: [email protected]
Abstract Myanmar Tobacco Control Law of 2006 covers the control of all forms of tobacco use. After 7‑year, tobacco use among adults did not see a decrease. The paper aimed to study the prevalence, details of the products, trade, legislation, tax, marketing, advertising and evidence on morbidity and mortality, and to make recommendations for policy options. Personal communications by authors and colleagues, and searches by keywords in PubMed and on Google, literature review and research from published reports, and various studies and surveys conducted in Myanmar and other countries. Smokeless tobacco use in Myanmar is the highest among ASEAN countries. A variety of SLT products used together with betel chewing poses a challenge; betel quid chewing has been accepted as a cultural norm in both rural and urban areas. Betel quid chewing usually starts at younger ages. Sale, marketing, and advertising of SLT are not under control and thus, road‑side kiosks selling betel quid with SLT are mushrooming. Considerable trade of SLT products by illegal and legal means created an increase in access and availability. Low cost of SLT product enables high volume of use, even for the poor families. Taxation for raw tobacco and tobacco products is half the values of the tax for cigarettes. Effective enforcement, amendment of the law, and action for social change are needed. Key Words: Culture, Myanmar, prevalence, smokeless tobacco, tobacco control
Introduction The use of smokeless tobacco (SLT) in Myanmar in 2009 among adult males was around 51% and that of females, around 16%, which is the highest amongst Association of Southeast Asian Nations (ASEAN) countries.[1] The Ministry of Health in Myanmar is working toward strengthening its national tobacco control legislation adopted since 2006,[2] and thus, it is imperative that the national policies and programs are tailored to address the unique characteristics of SLT use. The paper aimed to review the prevalence, details of the products, trade, marketing, advertising, legislation and taxation, and evidence on morbidity and mortality and to make recommendations for policy options. Materials and Methods The data sources for this review were obtained from published reports and documents, research findings and personal communication. These included studies and surveys conducted in Myanmar such as: Sentinel prevalence survey on tobacco use in 2001, 2004, and 2007, Global Youth Tobacco Surveys (GYTS) in 2001, 2007, and 2011, school tobacco control study in 2011, noncommunicable diseases (NCD) risk factor survey in Myanmar, 2009, national seminars and workshops, personal observations and communications by authors and colleagues, and searches by keywords in PubMed and on Google. Findings Types of smokeless tobacco
The most common product of SLT in Myanmar is raw and cured tobacco (known as hsey or hsey‑ywet kyee). A variety of SLT products are used as the main condiments in Kun Yar‑Myanmar version of betel quid. A few widely available products are: Dried raw tobacco leaves (Hsey or Hsey Wah), Access this article online Quick Response Code:
Website: www.indianjcancer.com DOI: 10.4103/0019-509X.147416 PMID: *******
Indian Journal of Cancer | Dec 2014 | Volume 51 | Supplement 1
cured and roasted tobacco leaves (Hsey Me’), tobacco leaves treated with alcohol and honey (Hsey Paung or Hnut Hsey), scented tobacco soaked in honey, lime juice and water (Hsey Paung Yay or Black Water), and other varieties of tobacco mixture added with fragrances (Hsey Hmwe). While most tobacco products are produced locally, a few popular SLT products such as 92, Signal 350, Parijat, Queen, and Baba brands are imported from India and Bangladesh. Some are produced in border areas and marketed as imported products. The recent ban of tobacco and nicotine in any food product sold in the majority of states in India[3] has led to a greater influx and availability in large quantities. The price of a piece of Kun Yar is largely dependent on the contents and brand of tobacco products. Cultural background Cultural practices
Chewing Kun Yar (the betel quid) dates back to Pyu‑Pagan Era (around 500–1000 AD), and it is interwoven into social customs and religious practices.[4] Undoubtedly, this deeply rooted cultural practice has contributed to an alarmingly high prevalence of SLT users. The term Kun Ywet (betel vine leaf) and Kun It (a multi‑layer fancy lacquered box to hold the ingredients of Kun Yar) are the basic vocabulary words taught to primary school children in their Myanmar reading textbooks for Grade 1 and Grade 2. In many parts of Myanmar, it is a widely accepted behavior for young kids to chew betel quid with tobacco, without knowing the implications in later life. Betel preparation (without tobacco) has been fed to the children as a digestive aid and mouth freshener. Later, young children learn to add tobacco in the preparation. In rural Myanmar, women chewing raw tobacco or consuming betel quid with SLT is generally accepted by society. When the parents are consumers of betel quid with SLT, their children and other family members are more likely to start consuming SLT. Young consumers of SLT are more likely to maintain this habit in their later lives. In some rural areas, ethnic population are fond of keeping small pieces of raw tobacco inside the mouth for a long time. They are also proud of having blackened teeth and tongue after long use of SLT. S3
Sein, et al.: Challenges of SLT use in Myanmar
Insufficient knowledge
Majority of SLT users are truck and bus drivers, motorcycle and rickshaw drivers, bus and restaurant attendants, tea‑shop waiters, manual laborers, and housewives. They believe that consuming SLT products is a way to maintain “attention” and “focus,” and also claim that use of SLT helps them work harder, and work for longer periods.[5] Youths tend to have misconceived notions on immediate stimulant effects of nicotine and long‑term health impacts of SLT. Much of the rural population still does not believe that long‑term SLT consumption can lead to oral and pharyngeal cancer. Furthermore, there is a common misconception that SLT products are less harmful than smoking tobacco. This results in ill‑informed practices of use of SLT as a smoking substitute and aid for smoking cessation. The gap in knowledge on effects of use of tobacco is markedly greater in lower socioeconomic groups, where the proportion of tobacco usage is significantly higher. Production and trade
While the land area used for betel nuts (areca nuts) remained about the same (12,000 acres) from 2000 to 2005, the land used for betel‑vine leaves had been almost doubled from 9000 to 19,000 acres. Many small‑scale betel‑vine leaf growers termed this growth as the “Green Gold era.” Since the tobacco is competitive with other cash crops, it is highly subsidized by cigarette companies, and its cultivation and processing are assisted by soft loans from private companies. There was a steady increase in imports of tobacco products in the 1990s coinciding with increases in local production of all tobacco products reaching nearly 7000 metric tons of import by 2006.[6] There is a considerable import of SLT products through legal and illegal means, reflecting increases in overall consumption. Unethical trade practices have come up like mixing the original imported products with local tobacco, and repacking them under local brand names, and sold at significantly cheaper prices. One such product popular in Myanmar is “162 or Sardar.” Most of the imported SLT product containers have a prominent health warning. For example, original tobacco containers from India had mandatory warning messages and pictures. Re‑packaged local containers do not contain any comparable health warning, indication of ingredients or age‑restrictions.[7] Efforts should be prioritized for law enforcement as well as an amendment of the existing national law to include the control of SLT products, including repackaging and illicit trade. Marketing and sale
Myanmar Tobacco Control Law has stipulated the total ban on advertisement, sale and distribution and sponsorship of cigarettes and other tobacco products. Despite this, the total number of SLT consumers have steadily increased, as a result of the uncontrolled proliferation of small and big road‑side kiosks and stalls in every tea‑shop selling cigarettes and betel quids. These kiosks and stalls have the posters and sale promotions for cigarettes and other tobacco products. Unlike other ASEAN nations, these SLT products are displayed and sold openly, acting as a point of sale advertisements strongly linked and controlled by S4
the SLT wholesalers.[8] A comprehensive ban on displaying, advertising and promoting the sale of cigarettes in all media have been implemented during the last several years. With the recent change in censorship policy, many scenes showing tobacco smoking and SLT consumption by movie stars in Myanmar films and videos (TV/VCD/DVD) have come back. Some reruns of old videos/films of foreign sources have censorship applied for smoking (blurring out cigarettes), yet the ban is not consistent. Banning the consumption of SLT products in the public media has not yet been implemented. Youths today perceive that sharing Kun Yar or cigarette is a friendly gesture of comradeship, as well as a break time activity. The SLT products are sold in Myanmar in loose form or in plastic pouches, without mentioning either the “origin of the product,” “the disclosure of contents” or the “health warning,” due to lack of stringent regulation. At some super markets, ready‑made betel quid preparations containing tobacco products, wrapped in plastic pouches in metal containers, are available as refrigerated items, except for a label indicating that the sale to under 18 years is prohibited.[9] To ensure that points of sale of tobacco products do not have any promotional elements, the legislative framework needs to be strengthened to introduce proper package labeling, total ban on any display, and visibility of warnings on tobacco products at points of sale. Availability and price
The SLT products are widely available at affordable price. Strategically placed kiosks are present at every public location including schools, theaters, offices, markets, hospitals, clinics, university campuses, bus stops, restaurants, etc., The increase in youth consumption of SLT could also be contributed to by the fact that vendors do not discriminate consumers by age. Children as young as 8‑year‑old are seen buying and consuming betel quid, hawking products, preparing them in stalls, and selling prepackaged Kun Yar at major traffic junctions. Kun Yar using local tobacco is sold for 100 Kyats for four pieces (or 0.025 USD per piece). If popular Indian tobacco products are used, the price of the quid becomes double. Each consumer of SLT can ask their vendors for a particular amount and type of tobacco for preparation of their own pieces. The price of Kun Ywet (Betel leaf) fluctuates between 5000 and 7000 Kyats per viss (roughly 1.7 k), varying with seasonal yield. Each viss of Kun yields on average 500 individual leaves, depending on the size and condition of the leaves, estimating the baseline cost of each piece of Kun Yar to be around 10–12 Kyats. If lime, betel nuts, tobacco, and other ingredients are added, the overall vendor cost of a basic piece of Kun Yar is estimated at around 15–20 Kyats. The average Kun Yar roadside vendor will use 2–3 visses worth of Kun Ywet daily while larger stores will sell up to 10–30 visses per day.[10] Average daily gross income from selling betel quids will range from Kyats 10,000/‑ to Kyats 50,000/‑. The price of Kun Yar for 4 pieces (i.e. Kyats 100/‑) remains affordable to low‑income wagers, since average minimum daily wage Indian Journal of Cancer | Dec 2014 | Volume 51 | Supplement 1
Sein, et al.: Challenges of SLT use in Myanmar
for a manual laborer is around 2000/‑Kyats. Some SLT users chew up to 100 pieces of Kun Yar per day spending large portions of their daily income. The average consumer of SLT, chewing 20 pieces of betel quids per day, would have been able to purchase five eggs or one kilo of rice. Prevalence
Sentinel studies on tobacco use were conducted in the years 2001, 2004, and 2007 showed that while the prevalence of smoking is gradually declining, prevalence of SLT use like chewing of betel quid with tobacco is rising steadily among both sexes, in both rural and urban areas.[11] Myanmar, in comparison to other ASEAN countries, has an abnormally high prevalence of SLT consumption, especially among male adults. According to the ASEAN Tobacco Control Atlas published in 2013, 51% of males and 16% of females above the age of 15 of all regular tobacco users in Myanmar used SLT products. According to the World Health Organization (WHO), Non Communicable Diseases (NCD) Risk factor Survey conducted in 2009 in Myanmar, over 45% of youths (15–24 years male) consumed SLT products. The consumption was highest among 25–34 years old men (63%) and 45–54 years old women (32%). The proportion of women who use SLT is double that of smokers.[12] The Myanmar GYTS 2011, a school‑based survey of students aged 13–15 years in the 7th to 10th grades carried out in 2011, indicated that about one in five (18.6%) students were current users of any tobacco product, and 9.8% were current users of any SLT products, an increase from 6.5% in 2009. The prevalence of SLT use among boys was about four times higher than that in girls. Since there is a widespread detrimental myth that SLT is not as harmful as cigarettes, parents and teachers tend to show less concern if their children chew betel with tobacco than if they smoke.[13] Based on existing prevalence data, it is estimated that there would be around 10 million people of above 15‑year who are the regular SLT users. Tobacco‑related diseases
The trend in tobacco‑related diseases is steadily increasing in Myanmar. Available data shows that of total deaths in Myanmar, a staggering overall 39.3% among men and 40.1% among women were attributed to NCDs of which a substantial avoidable part may be due to SLT use.[14] In Myanmar, oral and oral‑pharyngeal cancers have consistently been the fifth most common cancers for both genders. A study in a suburban township of Yangon City in 2013 investigated the knowledge and practice of betel quid chewing of the local populace, and compared the prevalence of oral precancerous lesions between betel quid chewers and non-chewers. It was found that over 50% of adults surveyed used betel quid and 85% of current betel chewers used SLT products. Nearly 5% of the survey population had oral lesions (precancerous stage), all confined to current betel quid chewers.[15] A study of 36 cases of oral cancer patients recruited for the action study who expired within 1‑year after diagnosis, Indian Journal of Cancer | Dec 2014 | Volume 51 | Supplement 1
had been selected among patients admitted at University of Dental Medicine, Yangon from February 2012 to September 2013. Almost all oral cancer patients were over 40‑year old, and their mean age was 62‑year. Squamous cell carcinomas constituted 89%, and tongue was the most common site involved (42%). As for tumor staging, patients in stage IV constituted about 81%, which showed that the patients lacked the knowledge of the importance of early diagnosis and treatment. 56% of patients died early without any treatment. About 89% of these patients died due to cancer‑related causes, and only 11% expired due to other systemic diseases. The mean cost of treatment was Kyats 447,000/‑ (US$ 500/‑). Costs for cancer medicines and other drugs were and still remain expensive and were burdensome to low‑income families. [16] For those that swallow the juices of Kun Yar instead of spitting them out have also faced a greater risk of developing kidney stones. Current tobacco control measures
In compliance with the 2006 Tobacco Control Law, some establishments that people used to frequent or attend (e.g. sport stadiums, hospitals, restaurants, and schools) have begun implementing “smoke‑free” location rules, especially those located in townships that have begun complying with smoke‑free initiatives. While smoking has the added danger of second‑hand smoke, it is possible that due to the common misconception that SLT is less harmful, there is less emphasis on the control of SLT products in many places. The lack of urgency is misplaced because the proportion of SLT users is still significantly higher than that of smokers. Several establishments to which the general public including pregnant women and young children have access to have markedly begun posting “Kun Ta‑twe Ma Htwe Ya” (spitting of saliva from chewing Kun is prohibited) stickers, together with the “no smoking” signs. Such places include hospitals and health centers, public gardens, guest houses, hotels, restaurants, bus stations, railway stations, religious places as well as schools. The main purpose of these signs is meant for esthetic reasons. The paradigm needs to shift from prohibiting spitting and disposing of SLT products to a total ban on consuming SLT in all public establishments – a shift from hygiene measures to the health measures. A sign such as “Kun Ma Sa Ya” or “The consumption of Kun Yar is totally prohibited” would be more appropriate for promoting tobacco control. Recently, collaborative efforts of the People’s Health Foundation and the Ministries of Health and Education have started community‑based actions to implement demand reduction measures by launching “100% Tobacco‑Free areas” in selected townships. Tobacco taxation
The average price per cigarette pack is US$ 1.18 in low‑income countries, double in the Asia‑Pacific, and triple in the developed world. Taxation on tobacco products in many low‑income countries is an average of 50% of the retail price. In some middle‑ and high‑income countries, tobacco taxation is used as part of comprehensive strategies to reduce tobacco use and the tax on tobacco accounts for two‑third or more of the retail price. S5
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At present, taxation on tobacco and tobacco products is included under items for taxation of commodities of commercial values as shown in Annexure of the Commercial Tax Law in Myanmar. Under the Union Taxation Law of 2014,[17] a taxation structure for tobacco products local or imported remained as 100% commercial tax on cigarettes, 50% on raw tobacco, cheroots, cigars, and other tobacco products. While there is no taxation on locally produced areca nuts, there is a commercial tax of 5% for imported ones. Despite the implementation in Myanmar of taxation on tobacco and tobacco products, it remains the lowest cost for tobacco products and has had little impact on the sale and consumption of SLT products in Myanmar. Because the majority of tobacco users in Myanmar utilize SLT products, the policy should focus on increasing taxation in all respects of tobacco products, with specific reference to SLT products. The sale of SLT products in Myanmar is very profitable for both the legal and illegal SLT product companies and the street vendors alike. SLT product importers in Myanmar, especially those who import legally and illegally from neighbors have well‑established trade routes. Companies importing popular SLT products such as Bayinma (Queen), Signal, and 92, have maintained an extremely loyal customer base, and these products are spreading ubiquitously throughout Myanmar. Every street vendor of Kun Yar will almost always have 3–5 boxes of 2–3 famous brands in stock. In addition to the profitability of the industries producing SLT products, local vendors of SLT products continue to enjoy high income. A typical SLT vendor requires very little initial financial capital, and in return, enjoys sustainable and high profit margins. Commercial tax and profit tax are levied on all these vendors ranging from 0% to 50%, normally depending on the total sales value (cost of production plus overhead expenses). The trade of SLT products is a major industry that needs further study on production, sale, taxation, trade, social and economic aspects, and their regulation. If unchecked, the availability of these products will continue to grow and to be a major burden on healthcare in Myanmar. While countries all around the world, both developed and developing, adopted taxation for tobacco products for general revenue, several nations introduced a different form of tax– an earmarked or dedicated taxation. This dedicated tax not only aids in reducing consumption of a particular product, but also the proceeds could be used to further reduce the demand. In most countries, it is exclusively referred to as taxes levied on tobacco, alcohol, and gambling. The revenue thus collected is usually spent on social welfare, social insurance, health, and other development activities. Such a system of taxation in Myanmar would be of great benefit. Existing national tobacco legislation of 2006 covers mainly demand reduction, and thus, it needs to be updated with supply reduction, and thus, to become a comprehensive legislation, that would be in line with the WHO Framework Convention on Tobacco Control, and also in harmony with legislation of other ASEAN countries. Legislation could be S6
strengthened with additional measures targeting availability and accessibility of tobacco products, especially SLT, illicit trade, legal provision for support to tobacco growers with economically viable alternative activities, etc. It would also need to strengthen the regulation with respect to the limitation on contents and product disclosure, as well as health warning labels and advertising for all tobacco products. Myanmar had signed the Protocol to eliminate illicit trade in tobacco products a year ago. This Protocol aims at eliminating all forms of illicit trade in tobacco products, and provides tools for preventing and counteracting illicit trade through a package of national measures and international cooperation. Myanmar has already implemented a suite of measures to secure the supply chain of tobacco products, like licensing for the manufacture, import and export of tobacco products and manufacturing equipment. It still needs to establish a national or regional tracking and tracing system for all tobacco products that are manufactured in or imported into its territory for the purpose of investigating illicit trade. In order to implement effectively the ASEAN Free Trade Agreement by 2015, countries involved need to sign this Protocol, as well as its related instruments, to eliminate illicit trade in tobacco products as soon as possible. Appropriate price and tax control measures have to be implemented in order to raise the prices of tobacco products especially SLT since it is the most effective way to reduce consumption among youths and poor people. Price and tax measures should aim at increasing prices harmoniously for all tobacco products, both local and imported, in order to prevent substitution/smuggling. Effective enforcement and amendment of the law are needed, and a ministerial order which includes specific SLT products is highly recommended. According to the existing volume and the low prices for tobacco and tobacco products, the tobacco industries in Myanmar may claim that their price structure is modest. In reality, the price for tobacco and tobacco products in Myanmar is one of the lowest among ASEAN and there is room to raise the price without affecting affordability to the poor who use those products most, and also benefiting millions of people using the tax revenue effectively. Myanmar health policy makers have to explore the potential feasibility of establishing innovative financing for health promotion by introducing hypothecated taxation of tobacco and its products, necessary for effective implementation of tobacco control measures and other health promotion activities. Myanmar could implement similar measures for banning tobacco and nicotine from food products similar to the regulations of Food Safety and Standards Authority of India adopted in 2011. In the interest of public health, a comprehensive ban on all chewing tobacco products should be enforced. The initiative and participation of national institutions, including those responsible for health policy, health systems research and strategic studies, essential for initiating the Indian Journal of Cancer | Dec 2014 | Volume 51 | Supplement 1
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periodic collection of national evidence‑based information on tobacco use‑related knowledge, attitudes, and practices. Programs need to focus on shifting the community’s perception of SLT, such as to change focus from hygiene to the health, and other misconceptions about SLT. Community‑wide efforts on implementing No‑Tobacco or Tobacco‑free are required. Appropriate price and tax measures have to be implemented in order to raise the prices of tobacco products since this is the most effective way to reduce consumption. Ultimately, the legislation is possible, but not without the support and involvement of the people.
6. 7. 8.
9.
Conclusions Prevalence of SLT use is high. There is a high incidence of oral and oropharyngeal cancer. Taxation on SLT products is low and SLT control is not well‑addressed under tobacco control policy. There is a lack of research on SLT products in Myanmar. Myanmar needs to strengthen SLT control policies. Acknowledgments Authors wish to thank WHO Regional Office for South‑East Asia, New Delhi for their technical support, and the Ministry of Health, Myanmar for permission to use their studies to be referred and analyzed.
References 1. 2. 3. 4. 5.
SEATCA. ASEAN Tobacco Control Atlas. 1st ed. Thailand: South‑East Asia Tobacco Control Alliance; 2013. p. 5. The Control of Smoking and Consumption of Tobacco Product Law (State Peace and Development Council Law No. 5/2006), The New Light of Myanmar; Friday, 5 May 2006. Arora M, Madhu R. Banning smokeless tobacco in India: Policy analysis. Indian J Cancer 2012;49:336‑41. Sein T, Maung NS. Tobacco legislation and ways of tobacco industry in Myanmar, Draft Report to WHO SEARO. Yangon: University of Public Health; 2012. Kyaing NN, Perucic A, Rahman K. Study on poverty alleviation and tobacco
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10. 11. 12. 13. 14. 15.
16.
17.
control in Myanmar, HNP Discussion Paper, Economics of Tobacco Control Paper, No. 31, World Bank and WHO; 2005. Available from: http:// www.documents.worldbank.org/curated/en/2005/09/6362046/ study‑poverty‑alleviation‑tobacco‑control‑myanmar. [Last accessed on 2014 Mar 07]. Central Statistical Organization. Myanmar Statistical Year Book. Naypyidaw: Ministry of National Planning and Economic Development; 2008. Toe MM. Personal communication on review of tobacco products in major cities. 2014. Available from: http://[email protected]. People’s Health Foundation. Report on Advocacy Workshop on Ban of Tobacco Advertising, Promotion and Sponsorship Held at the University of Public Health, Yangon, June 2013 (unpublished uthansein@gmail. com), Myanmar; 2013. People’s Health Foundation. Report on Advocacy Workshop on Warning Against Dangers of Tobacco: Packaging and Labelling, Held at the University of Public Health, Yangon, April 2013 (unpublished uthansein@ gmail.com), Myanmar; 2013. Toe MM. Sample Study on Availability of Smokeless Tobacco in Major Cities. 2014. (unpublished [email protected]). Ministry of Health. Official Report to WHO SEARO for Global Tobacco Control Report 2012. Myanmar: National Tobacco Control Programme; 2012. World Health Organization. NCD Risk Factor Survey Myanmar, 2009. WHO Regional Office for South‑East Asia. New Delhi, WHO SEARO (Doc. SEA‑TOB‑40), 2011. World Health Organization. Factsheet on Global Youth Tobacco Survey: Myanmar. WHO Regional Office for South‑East Asia. New Delhi: WHO SEARO; 2011. World Health Organization. Global Burden of Disease, 2004 Update. Geneva: WHO; 2008. Ko Ko Zaw, Ohnmar M, Hlaing MM, Win SS, Than Htike MM, Aye PP. et al. Betel Quid Chewing in Dagon (East) Township in 2013, A Paper Presented at the Myanmar Medical Research Congress, January 2014, Department of Medical Research (Lower Myanmar), Yangon; 2014. Thane MM, Win LL, Win SS. A preliminary analysis of oral cancer patients in ASEAN: Costs in Oncology Study‑Myanmar (ACTION Study) 2013, University of Dental Medicine, Yangon, A paper Presented at the Myanmar Medical Research Congress, January 2014, Department of Medical Research (Lower Myanmar), Yangon; 2014. The Union Taxation Law, 28 March, 2014, (in Myanmar as appeared in Myanma Ahlin Newspaper dated 4 April 2014). How to site this article: Sein T, Swe T, Toe Mm, Zaw KK, Sein TO. Challenges of smokeless tobacco use in Myanmar. Indian J Cancer 2014;51:3-7. Source of Support: Nil. Conflict of Interest: None declared.
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Challenges of smokeless tobacco use in Myanmar Sein T, Swe T, Toe MM1, Zaw KK2, Sein TO People’s Health Foundation, 1Department of Medical Research (Central Myanmar), Nay Pyi Taw, Myanmar, 2Department of Medical Research (Lower Myanmar), Yangon Correspondence to: Dr. Than Sein, E‑mail: [email protected]
Abstract Myanmar Tobacco Control Law of 2006 covers the control of all forms of tobacco use. After 7‑year, tobacco use among adults did not see a decrease. The paper aimed to study the prevalence, details of the products, trade, legislation, tax, marketing, advertising and evidence on morbidity and mortality, and to make recommendations for policy options. Personal communications by authors and colleagues, and searches by keywords in PubMed and on Google, literature review and research from published reports, and various studies and surveys conducted in Myanmar and other countries. Smokeless tobacco use in Myanmar is the highest among ASEAN countries. A variety of SLT products used together with betel chewing poses a challenge; betel quid chewing has been accepted as a cultural norm in both rural and urban areas. Betel quid chewing usually starts at younger ages. Sale, marketing, and advertising of SLT are not under control and thus, road‑side kiosks selling betel quid with SLT are mushrooming. Considerable trade of SLT products by illegal and legal means created an increase in access and availability. Low cost of SLT product enables high volume of use, even for the poor families. Taxation for raw tobacco and tobacco products is half the values of the tax for cigarettes. Effective enforcement, amendment of the law, and action for social change are needed. Key Words: Culture, Myanmar, prevalence, smokeless tobacco, tobacco control
Introduction The use of smokeless tobacco (SLT) in Myanmar in 2009 among adult males was around 51% and that of females, around 16%, which is the highest amongst Association of Southeast Asian Nations (ASEAN) countries.[1] The Ministry of Health in Myanmar is working toward strengthening its national tobacco control legislation adopted since 2006,[2] and thus, it is imperative that the national policies and programs are tailored to address the unique characteristics of SLT use. The paper aimed to review the prevalence, details of the products, trade, marketing, advertising, legislation and taxation, and evidence on morbidity and mortality and to make recommendations for policy options. Materials and Methods The data sources for this review were obtained from published reports and documents, research findings and personal communication. These included studies and surveys conducted in Myanmar such as: Sentinel prevalence survey on tobacco use in 2001, 2004, and 2007, Global Youth Tobacco Surveys (GYTS) in 2001, 2007, and 2011, school tobacco control study in 2011, noncommunicable diseases (NCD) risk factor survey in Myanmar, 2009, national seminars and workshops, personal observations and communications by authors and colleagues, and searches by keywords in PubMed and on Google. Findings Types of smokeless tobacco
The most common product of SLT in Myanmar is raw and cured tobacco (known as hsey or hsey‑ywet kyee). A variety of SLT products are used as the main condiments in Kun Yar‑Myanmar version of betel quid. A few widely available products are: Dried raw tobacco leaves (Hsey or Hsey Wah), Access this article online Quick Response Code:
Website: www.indianjcancer.com DOI: 10.4103/0019-509X.147416 PMID: *******
Indian Journal of Cancer | Dec 2014 | Volume 51 | Supplement 1
cured and roasted tobacco leaves (Hsey Me’), tobacco leaves treated with alcohol and honey (Hsey Paung or Hnut Hsey), scented tobacco soaked in honey, lime juice and water (Hsey Paung Yay or Black Water), and other varieties of tobacco mixture added with fragrances (Hsey Hmwe). While most tobacco products are produced locally, a few popular SLT products such as 92, Signal 350, Parijat, Queen, and Baba brands are imported from India and Bangladesh. Some are produced in border areas and marketed as imported products. The recent ban of tobacco and nicotine in any food product sold in the majority of states in India[3] has led to a greater influx and availability in large quantities. The price of a piece of Kun Yar is largely dependent on the contents and brand of tobacco products. Cultural background Cultural practices
Chewing Kun Yar (the betel quid) dates back to Pyu‑Pagan Era (around 500–1000 AD), and it is interwoven into social customs and religious practices.[4] Undoubtedly, this deeply rooted cultural practice has contributed to an alarmingly high prevalence of SLT users. The term Kun Ywet (betel vine leaf) and Kun It (a multi‑layer fancy lacquered box to hold the ingredients of Kun Yar) are the basic vocabulary words taught to primary school children in their Myanmar reading textbooks for Grade 1 and Grade 2. In many parts of Myanmar, it is a widely accepted behavior for young kids to chew betel quid with tobacco, without knowing the implications in later life. Betel preparation (without tobacco) has been fed to the children as a digestive aid and mouth freshener. Later, young children learn to add tobacco in the preparation. In rural Myanmar, women chewing raw tobacco or consuming betel quid with SLT is generally accepted by society. When the parents are consumers of betel quid with SLT, their children and other family members are more likely to start consuming SLT. Young consumers of SLT are more likely to maintain this habit in their later lives. In some rural areas, ethnic population are fond of keeping small pieces of raw tobacco inside the mouth for a long time. They are also proud of having blackened teeth and tongue after long use of SLT. S3
Sein, et al.: Challenges of SLT use in Myanmar
Insufficient knowledge
Majority of SLT users are truck and bus drivers, motorcycle and rickshaw drivers, bus and restaurant attendants, tea‑shop waiters, manual laborers, and housewives. They believe that consuming SLT products is a way to maintain “attention” and “focus,” and also claim that use of SLT helps them work harder, and work for longer periods.[5] Youths tend to have misconceived notions on immediate stimulant effects of nicotine and long‑term health impacts of SLT. Much of the rural population still does not believe that long‑term SLT consumption can lead to oral and pharyngeal cancer. Furthermore, there is a common misconception that SLT products are less harmful than smoking tobacco. This results in ill‑informed practices of use of SLT as a smoking substitute and aid for smoking cessation. The gap in knowledge on effects of use of tobacco is markedly greater in lower socioeconomic groups, where the proportion of tobacco usage is significantly higher. Production and trade
While the land area used for betel nuts (areca nuts) remained about the same (12,000 acres) from 2000 to 2005, the land used for betel‑vine leaves had been almost doubled from 9000 to 19,000 acres. Many small‑scale betel‑vine leaf growers termed this growth as the “Green Gold era.” Since the tobacco is competitive with other cash crops, it is highly subsidized by cigarette companies, and its cultivation and processing are assisted by soft loans from private companies. There was a steady increase in imports of tobacco products in the 1990s coinciding with increases in local production of all tobacco products reaching nearly 7000 metric tons of import by 2006.[6] There is a considerable import of SLT products through legal and illegal means, reflecting increases in overall consumption. Unethical trade practices have come up like mixing the original imported products with local tobacco, and repacking them under local brand names, and sold at significantly cheaper prices. One such product popular in Myanmar is “162 or Sardar.” Most of the imported SLT product containers have a prominent health warning. For example, original tobacco containers from India had mandatory warning messages and pictures. Re‑packaged local containers do not contain any comparable health warning, indication of ingredients or age‑restrictions.[7] Efforts should be prioritized for law enforcement as well as an amendment of the existing national law to include the control of SLT products, including repackaging and illicit trade. Marketing and sale
Myanmar Tobacco Control Law has stipulated the total ban on advertisement, sale and distribution and sponsorship of cigarettes and other tobacco products. Despite this, the total number of SLT consumers have steadily increased, as a result of the uncontrolled proliferation of small and big road‑side kiosks and stalls in every tea‑shop selling cigarettes and betel quids. These kiosks and stalls have the posters and sale promotions for cigarettes and other tobacco products. Unlike other ASEAN nations, these SLT products are displayed and sold openly, acting as a point of sale advertisements strongly linked and controlled by S4
the SLT wholesalers.[8] A comprehensive ban on displaying, advertising and promoting the sale of cigarettes in all media have been implemented during the last several years. With the recent change in censorship policy, many scenes showing tobacco smoking and SLT consumption by movie stars in Myanmar films and videos (TV/VCD/DVD) have come back. Some reruns of old videos/films of foreign sources have censorship applied for smoking (blurring out cigarettes), yet the ban is not consistent. Banning the consumption of SLT products in the public media has not yet been implemented. Youths today perceive that sharing Kun Yar or cigarette is a friendly gesture of comradeship, as well as a break time activity. The SLT products are sold in Myanmar in loose form or in plastic pouches, without mentioning either the “origin of the product,” “the disclosure of contents” or the “health warning,” due to lack of stringent regulation. At some super markets, ready‑made betel quid preparations containing tobacco products, wrapped in plastic pouches in metal containers, are available as refrigerated items, except for a label indicating that the sale to under 18 years is prohibited.[9] To ensure that points of sale of tobacco products do not have any promotional elements, the legislative framework needs to be strengthened to introduce proper package labeling, total ban on any display, and visibility of warnings on tobacco products at points of sale. Availability and price
The SLT products are widely available at affordable price. Strategically placed kiosks are present at every public location including schools, theaters, offices, markets, hospitals, clinics, university campuses, bus stops, restaurants, etc., The increase in youth consumption of SLT could also be contributed to by the fact that vendors do not discriminate consumers by age. Children as young as 8‑year‑old are seen buying and consuming betel quid, hawking products, preparing them in stalls, and selling prepackaged Kun Yar at major traffic junctions. Kun Yar using local tobacco is sold for 100 Kyats for four pieces (or 0.025 USD per piece). If popular Indian tobacco products are used, the price of the quid becomes double. Each consumer of SLT can ask their vendors for a particular amount and type of tobacco for preparation of their own pieces. The price of Kun Ywet (Betel leaf) fluctuates between 5000 and 7000 Kyats per viss (roughly 1.7 k), varying with seasonal yield. Each viss of Kun yields on average 500 individual leaves, depending on the size and condition of the leaves, estimating the baseline cost of each piece of Kun Yar to be around 10–12 Kyats. If lime, betel nuts, tobacco, and other ingredients are added, the overall vendor cost of a basic piece of Kun Yar is estimated at around 15–20 Kyats. The average Kun Yar roadside vendor will use 2–3 visses worth of Kun Ywet daily while larger stores will sell up to 10–30 visses per day.[10] Average daily gross income from selling betel quids will range from Kyats 10,000/‑ to Kyats 50,000/‑. The price of Kun Yar for 4 pieces (i.e. Kyats 100/‑) remains affordable to low‑income wagers, since average minimum daily wage Indian Journal of Cancer | Dec 2014 | Volume 51 | Supplement 1
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for a manual laborer is around 2000/‑Kyats. Some SLT users chew up to 100 pieces of Kun Yar per day spending large portions of their daily income. The average consumer of SLT, chewing 20 pieces of betel quids per day, would have been able to purchase five eggs or one kilo of rice. Prevalence
Sentinel studies on tobacco use were conducted in the years 2001, 2004, and 2007 showed that while the prevalence of smoking is gradually declining, prevalence of SLT use like chewing of betel quid with tobacco is rising steadily among both sexes, in both rural and urban areas.[11] Myanmar, in comparison to other ASEAN countries, has an abnormally high prevalence of SLT consumption, especially among male adults. According to the ASEAN Tobacco Control Atlas published in 2013, 51% of males and 16% of females above the age of 15 of all regular tobacco users in Myanmar used SLT products. According to the World Health Organization (WHO), Non Communicable Diseases (NCD) Risk factor Survey conducted in 2009 in Myanmar, over 45% of youths (15–24 years male) consumed SLT products. The consumption was highest among 25–34 years old men (63%) and 45–54 years old women (32%). The proportion of women who use SLT is double that of smokers.[12] The Myanmar GYTS 2011, a school‑based survey of students aged 13–15 years in the 7th to 10th grades carried out in 2011, indicated that about one in five (18.6%) students were current users of any tobacco product, and 9.8% were current users of any SLT products, an increase from 6.5% in 2009. The prevalence of SLT use among boys was about four times higher than that in girls. Since there is a widespread detrimental myth that SLT is not as harmful as cigarettes, parents and teachers tend to show less concern if their children chew betel with tobacco than if they smoke.[13] Based on existing prevalence data, it is estimated that there would be around 10 million people of above 15‑year who are the regular SLT users. Tobacco‑related diseases
The trend in tobacco‑related diseases is steadily increasing in Myanmar. Available data shows that of total deaths in Myanmar, a staggering overall 39.3% among men and 40.1% among women were attributed to NCDs of which a substantial avoidable part may be due to SLT use.[14] In Myanmar, oral and oral‑pharyngeal cancers have consistently been the fifth most common cancers for both genders. A study in a suburban township of Yangon City in 2013 investigated the knowledge and practice of betel quid chewing of the local populace, and compared the prevalence of oral precancerous lesions between betel quid chewers and non-chewers. It was found that over 50% of adults surveyed used betel quid and 85% of current betel chewers used SLT products. Nearly 5% of the survey population had oral lesions (precancerous stage), all confined to current betel quid chewers.[15] A study of 36 cases of oral cancer patients recruited for the action study who expired within 1‑year after diagnosis, Indian Journal of Cancer | Dec 2014 | Volume 51 | Supplement 1
had been selected among patients admitted at University of Dental Medicine, Yangon from February 2012 to September 2013. Almost all oral cancer patients were over 40‑year old, and their mean age was 62‑year. Squamous cell carcinomas constituted 89%, and tongue was the most common site involved (42%). As for tumor staging, patients in stage IV constituted about 81%, which showed that the patients lacked the knowledge of the importance of early diagnosis and treatment. 56% of patients died early without any treatment. About 89% of these patients died due to cancer‑related causes, and only 11% expired due to other systemic diseases. The mean cost of treatment was Kyats 447,000/‑ (US$ 500/‑). Costs for cancer medicines and other drugs were and still remain expensive and were burdensome to low‑income families. [16] For those that swallow the juices of Kun Yar instead of spitting them out have also faced a greater risk of developing kidney stones. Current tobacco control measures
In compliance with the 2006 Tobacco Control Law, some establishments that people used to frequent or attend (e.g. sport stadiums, hospitals, restaurants, and schools) have begun implementing “smoke‑free” location rules, especially those located in townships that have begun complying with smoke‑free initiatives. While smoking has the added danger of second‑hand smoke, it is possible that due to the common misconception that SLT is less harmful, there is less emphasis on the control of SLT products in many places. The lack of urgency is misplaced because the proportion of SLT users is still significantly higher than that of smokers. Several establishments to which the general public including pregnant women and young children have access to have markedly begun posting “Kun Ta‑twe Ma Htwe Ya” (spitting of saliva from chewing Kun is prohibited) stickers, together with the “no smoking” signs. Such places include hospitals and health centers, public gardens, guest houses, hotels, restaurants, bus stations, railway stations, religious places as well as schools. The main purpose of these signs is meant for esthetic reasons. The paradigm needs to shift from prohibiting spitting and disposing of SLT products to a total ban on consuming SLT in all public establishments – a shift from hygiene measures to the health measures. A sign such as “Kun Ma Sa Ya” or “The consumption of Kun Yar is totally prohibited” would be more appropriate for promoting tobacco control. Recently, collaborative efforts of the People’s Health Foundation and the Ministries of Health and Education have started community‑based actions to implement demand reduction measures by launching “100% Tobacco‑Free areas” in selected townships. Tobacco taxation
The average price per cigarette pack is US$ 1.18 in low‑income countries, double in the Asia‑Pacific, and triple in the developed world. Taxation on tobacco products in many low‑income countries is an average of 50% of the retail price. In some middle‑ and high‑income countries, tobacco taxation is used as part of comprehensive strategies to reduce tobacco use and the tax on tobacco accounts for two‑third or more of the retail price. S5
Sein, et al.: Challenges of SLT use in Myanmar
At present, taxation on tobacco and tobacco products is included under items for taxation of commodities of commercial values as shown in Annexure of the Commercial Tax Law in Myanmar. Under the Union Taxation Law of 2014,[17] a taxation structure for tobacco products local or imported remained as 100% commercial tax on cigarettes, 50% on raw tobacco, cheroots, cigars, and other tobacco products. While there is no taxation on locally produced areca nuts, there is a commercial tax of 5% for imported ones. Despite the implementation in Myanmar of taxation on tobacco and tobacco products, it remains the lowest cost for tobacco products and has had little impact on the sale and consumption of SLT products in Myanmar. Because the majority of tobacco users in Myanmar utilize SLT products, the policy should focus on increasing taxation in all respects of tobacco products, with specific reference to SLT products. The sale of SLT products in Myanmar is very profitable for both the legal and illegal SLT product companies and the street vendors alike. SLT product importers in Myanmar, especially those who import legally and illegally from neighbors have well‑established trade routes. Companies importing popular SLT products such as Bayinma (Queen), Signal, and 92, have maintained an extremely loyal customer base, and these products are spreading ubiquitously throughout Myanmar. Every street vendor of Kun Yar will almost always have 3–5 boxes of 2–3 famous brands in stock. In addition to the profitability of the industries producing SLT products, local vendors of SLT products continue to enjoy high income. A typical SLT vendor requires very little initial financial capital, and in return, enjoys sustainable and high profit margins. Commercial tax and profit tax are levied on all these vendors ranging from 0% to 50%, normally depending on the total sales value (cost of production plus overhead expenses). The trade of SLT products is a major industry that needs further study on production, sale, taxation, trade, social and economic aspects, and their regulation. If unchecked, the availability of these products will continue to grow and to be a major burden on healthcare in Myanmar. While countries all around the world, both developed and developing, adopted taxation for tobacco products for general revenue, several nations introduced a different form of tax– an earmarked or dedicated taxation. This dedicated tax not only aids in reducing consumption of a particular product, but also the proceeds could be used to further reduce the demand. In most countries, it is exclusively referred to as taxes levied on tobacco, alcohol, and gambling. The revenue thus collected is usually spent on social welfare, social insurance, health, and other development activities. Such a system of taxation in Myanmar would be of great benefit. Existing national tobacco legislation of 2006 covers mainly demand reduction, and thus, it needs to be updated with supply reduction, and thus, to become a comprehensive legislation, that would be in line with the WHO Framework Convention on Tobacco Control, and also in harmony with legislation of other ASEAN countries. Legislation could be S6
strengthened with additional measures targeting availability and accessibility of tobacco products, especially SLT, illicit trade, legal provision for support to tobacco growers with economically viable alternative activities, etc. It would also need to strengthen the regulation with respect to the limitation on contents and product disclosure, as well as health warning labels and advertising for all tobacco products. Myanmar had signed the Protocol to eliminate illicit trade in tobacco products a year ago. This Protocol aims at eliminating all forms of illicit trade in tobacco products, and provides tools for preventing and counteracting illicit trade through a package of national measures and international cooperation. Myanmar has already implemented a suite of measures to secure the supply chain of tobacco products, like licensing for the manufacture, import and export of tobacco products and manufacturing equipment. It still needs to establish a national or regional tracking and tracing system for all tobacco products that are manufactured in or imported into its territory for the purpose of investigating illicit trade. In order to implement effectively the ASEAN Free Trade Agreement by 2015, countries involved need to sign this Protocol, as well as its related instruments, to eliminate illicit trade in tobacco products as soon as possible. Appropriate price and tax control measures have to be implemented in order to raise the prices of tobacco products especially SLT since it is the most effective way to reduce consumption among youths and poor people. Price and tax measures should aim at increasing prices harmoniously for all tobacco products, both local and imported, in order to prevent substitution/smuggling. Effective enforcement and amendment of the law are needed, and a ministerial order which includes specific SLT products is highly recommended. According to the existing volume and the low prices for tobacco and tobacco products, the tobacco industries in Myanmar may claim that their price structure is modest. In reality, the price for tobacco and tobacco products in Myanmar is one of the lowest among ASEAN and there is room to raise the price without affecting affordability to the poor who use those products most, and also benefiting millions of people using the tax revenue effectively. Myanmar health policy makers have to explore the potential feasibility of establishing innovative financing for health promotion by introducing hypothecated taxation of tobacco and its products, necessary for effective implementation of tobacco control measures and other health promotion activities. Myanmar could implement similar measures for banning tobacco and nicotine from food products similar to the regulations of Food Safety and Standards Authority of India adopted in 2011. In the interest of public health, a comprehensive ban on all chewing tobacco products should be enforced. The initiative and participation of national institutions, including those responsible for health policy, health systems research and strategic studies, essential for initiating the Indian Journal of Cancer | Dec 2014 | Volume 51 | Supplement 1
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periodic collection of national evidence‑based information on tobacco use‑related knowledge, attitudes, and practices. Programs need to focus on shifting the community’s perception of SLT, such as to change focus from hygiene to the health, and other misconceptions about SLT. Community‑wide efforts on implementing No‑Tobacco or Tobacco‑free are required. Appropriate price and tax measures have to be implemented in order to raise the prices of tobacco products since this is the most effective way to reduce consumption. Ultimately, the legislation is possible, but not without the support and involvement of the people.
6. 7. 8.
9.
Conclusions Prevalence of SLT use is high. There is a high incidence of oral and oropharyngeal cancer. Taxation on SLT products is low and SLT control is not well‑addressed under tobacco control policy. There is a lack of research on SLT products in Myanmar. Myanmar needs to strengthen SLT control policies. Acknowledgments Authors wish to thank WHO Regional Office for South‑East Asia, New Delhi for their technical support, and the Ministry of Health, Myanmar for permission to use their studies to be referred and analyzed.
References 1. 2. 3. 4. 5.
SEATCA. ASEAN Tobacco Control Atlas. 1st ed. Thailand: South‑East Asia Tobacco Control Alliance; 2013. p. 5. The Control of Smoking and Consumption of Tobacco Product Law (State Peace and Development Council Law No. 5/2006), The New Light of Myanmar; Friday, 5 May 2006. Arora M, Madhu R. Banning smokeless tobacco in India: Policy analysis. Indian J Cancer 2012;49:336‑41. Sein T, Maung NS. Tobacco legislation and ways of tobacco industry in Myanmar, Draft Report to WHO SEARO. Yangon: University of Public Health; 2012. Kyaing NN, Perucic A, Rahman K. Study on poverty alleviation and tobacco
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10. 11. 12. 13. 14. 15.
16.
17.
control in Myanmar, HNP Discussion Paper, Economics of Tobacco Control Paper, No. 31, World Bank and WHO; 2005. Available from: http:// www.documents.worldbank.org/curated/en/2005/09/6362046/ study‑poverty‑alleviation‑tobacco‑control‑myanmar. [Last accessed on 2014 Mar 07]. Central Statistical Organization. Myanmar Statistical Year Book. Naypyidaw: Ministry of National Planning and Economic Development; 2008. Toe MM. Personal communication on review of tobacco products in major cities. 2014. Available from: http://[email protected]. People’s Health Foundation. Report on Advocacy Workshop on Ban of Tobacco Advertising, Promotion and Sponsorship Held at the University of Public Health, Yangon, June 2013 (unpublished uthansein@gmail. com), Myanmar; 2013. People’s Health Foundation. Report on Advocacy Workshop on Warning Against Dangers of Tobacco: Packaging and Labelling, Held at the University of Public Health, Yangon, April 2013 (unpublished uthansein@ gmail.com), Myanmar; 2013. Toe MM. Sample Study on Availability of Smokeless Tobacco in Major Cities. 2014. (unpublished [email protected]). Ministry of Health. Official Report to WHO SEARO for Global Tobacco Control Report 2012. Myanmar: National Tobacco Control Programme; 2012. World Health Organization. NCD Risk Factor Survey Myanmar, 2009. WHO Regional Office for South‑East Asia. New Delhi, WHO SEARO (Doc. SEA‑TOB‑40), 2011. World Health Organization. Factsheet on Global Youth Tobacco Survey: Myanmar. WHO Regional Office for South‑East Asia. New Delhi: WHO SEARO; 2011. World Health Organization. Global Burden of Disease, 2004 Update. Geneva: WHO; 2008. Ko Ko Zaw, Ohnmar M, Hlaing MM, Win SS, Than Htike MM, Aye PP. et al. Betel Quid Chewing in Dagon (East) Township in 2013, A Paper Presented at the Myanmar Medical Research Congress, January 2014, Department of Medical Research (Lower Myanmar), Yangon; 2014. Thane MM, Win LL, Win SS. A preliminary analysis of oral cancer patients in ASEAN: Costs in Oncology Study‑Myanmar (ACTION Study) 2013, University of Dental Medicine, Yangon, A paper Presented at the Myanmar Medical Research Congress, January 2014, Department of Medical Research (Lower Myanmar), Yangon; 2014. The Union Taxation Law, 28 March, 2014, (in Myanmar as appeared in Myanma Ahlin Newspaper dated 4 April 2014). How to site this article: Sein T, Swe T, Toe Mm, Zaw KK, Sein TO. Challenges of smokeless tobacco use in Myanmar. Indian J Cancer 2014;51:3-7. Source of Support: Nil. Conflict of Interest: None declared.
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