The Extent of Illicit Cigarette Sales in Five Rural Districts of Pakistan: A Cross-sectional Study

Introduction The Illicit Tobacco Trade (ITT) subverts tobacco control efforts. Cigarette packs sold without legal health warnings undermine efforts to warn the public about the dangers of tobacco. Furthermore, cigarettes sold below minimum retail prices are indicative of tax evasion leading to revenue loss and budgetary deficits in high tobacco-burden economies. The extent of the ITT in rural areas of such countries might differ from urban. We estimated the extent of illicit cigarette sales in selected rural areas of Pakistan.Aims and Methods We analyzed cigarette packs collected from 85 villages in Pakistan as part of a cross-sectional consumer survey of 2550 rural households. We classified cigarette packs as noncompliant if these were missing: A text health warning, pictorial health warning (PHW), underage sale prohibition warning, retail price, or manufacturer details. To measure the extent of tax evasion, we estimated the proportion of packs purchased below the legal minimum retail price.Results Only 35% (429/1228) of rural smokers were able to show their cigarette packs. Out of these, 89% (382/429) of packs were noncompliant with the cigarette packaging and labeling laws. In rural areas, 83% (357/429) of packs did not have PHW and 33.8% (145/429) did not have printed retail prices. Among all packs, 41% (177/429) were purchased below the minimum retail price of 63 Pakistani Rupees and hence highly likely to have evaded taxes.Conclusions We found a very high previously unreported proportion of noncompliant cigarette packs in selected rural areas of Pakistan indicating weaker implementation of tobacco control laws in rural areas.Implications This paper presents previously unreported estimates of the share of illicit cigarette sales in rural areas of Pakistan. Most packs (89%) in our sample were noncompliant with the packaging and labeling regulations and a significant proportion (41%) were purchased below the minimum price. The extent of illicit tobacco was found to be far greater in rural than in urban areas of Pakistan. Taking advantage of poor law enforcement, the tobacco industry may be complicit in flooding the rural markets with illegal and cheap cigarettes. Given this disparity, law enforcement authorities must focus on rural areas.