Egypt: warning about the dangers of tobacco
Context
The Egyptian Law, specifically Law 1981/52, mandated the inclusion of textual health warnings on all tobacco products, whether locally produced or imported, as early as 1981. This significant development was the result of a prolonged battle led by the health committee of the parliament, spearheaded by a dedicated cardiologist. Violations of this law were subject to penalties such as imprisonment, fines, confiscation of non-compliant products and even the closure of factories or stores where these products were found. Later, Law 2002/85 amended the provisions of Law 1981/52 and specified that the textual health warnings should occupy at least 30% of the main display areas of the tobacco packaging, conveying the message "Beware smoking destroys health and causes death".
Initiative
Following Egypt's ratification of the WHO Framework Convention on Tobacco Control (FCTC), significant advancements were made in the regulation of packaging and labelling for tobacco products. Through Law 2007/154, Egypt explicitly acknowledged its commitments under the WHO FCTC and introduced several changes. The law mandated that the size of textual health warnings be increased to a minimum of 50% of the packaging, and it recommended the inclusion of additional textual warnings and pictorial health warnings, to be determined by a ministerial decree. Furthermore, it amended the provisions in Law 1981/52 to prohibit the use of misleading terms, such as "low tar", "light", "ultra-light" or "mild", which imply that a product is less harmful than others. Additionally, Law 2007/443 required that all tobacco packaging include a clear and visible textual health warning in Arabic, along with specified pictures illustrating smoking hazards on the heart, lungs and during pregnancy. These pictures are accompanied by relevant text, such as "Smoking causes heart problems", "Smoking causes lung cancer", "Smoking harms both smokers and non-smokers" and “Smoking kills and harms your health”.
Egypt achieved notable compliance with Article 11 of the WHO FCTC as early as 2008 and became one of the leading countries in the Eastern Mediterranean Region. In 2008, pictorial health warnings, aligned with the WHO FCTC Article 11 guidelines, were implemented, with a set of four rotating every two years. Since 2012, these warnings have also featured the help line number 16805. Additionally, a collection of 20 customized pictorial health warnings, accompanied by relevant text messages, was developed to meet Egypt's specific requirements. These warnings are available in the WHO FCTC Health Warnings Database. Currently, the selection of warnings is conducted by a panel of experts.
A draft bill proposing amendments to health warning labelling was submitted to the former Minister of Health however, it was not prioritized on the health agenda. The draft bill aimed to enlarge the size of pictorial health warnings and included plans for plain packaging.
Challenges and lessons learnt
The initiative highlighted the valuable lessons gained from close collaboration with WHO and other international organizations to implement evidence-based packaging and labelling for tobacco products. Furthermore, establishing stronger communication channels with the Ministry of Finance proved crucial in countering manipulations by the tobacco industry.
However, there are certain challenges and areas for improvement. The health warnings currently in use are generic and applied to both cigarette and waterpipe packaging, but there is a need for tailored messages specific to waterpipes and other tobacco products. Moreover, there is a lack of more effective requirements for tobacco packaging and labelling, such as placing warnings at the top of the pack and ensuring they are not obscured by any markings or tax stamps. It is also important to clarify that warnings do not absolve or reduce the liability of the tobacco industry. Additionally, there should be a prohibition on the use of figurative signs, misleading terms and descriptors that depict flavours, as well as the display of quantitative information on emission yields and expiry dates on tobacco packaging. Furthermore, due to insufficient financial resources, there is a lack of parallel anti-tobacco mass media campaigns during the launch of new warning sets. Lastly, there is currently no formal mechanism for pre- and post-testing the effectiveness of health warnings.
Impact
According to the Global Adult Tobacco Survey of 2009, nearly all cigarette smokers (98.2%) acknowledged the presence of health warnings on cigarette packs. Among them, almost half (44.6%) considered quitting smoking due to the warning labels. In contrast, 66.4% of current waterpipe smokers had noticed health warnings on waterpipe packs, but only a small percentage (3.0%) of them had contemplated quitting as a result of the warning label. This discrepancy may be attributed to the distinct nature of waterpipe smoking, where the tobacco is prepared away from the smoker in commercial waterpipe establishments.
Next steps
The National Plan for Tobacco Control includes objectives to enhance the size of pictorial health warnings to cover 85% of the pack's surface or potentially introduce plain packaging, if feasible. Additionally, the plan aims to create and execute impactful public awareness campaigns through various channels such as broadcast media (television and radio), print media (newspapers and magazines), and digital media platforms including YouTube, Facebook, Twitter, blogging platforms and mobile applications.
References
Global Adult Tobacco Survey 2009
MPOWER measures to reduce demand for tobacco
WHO Framework Convention on Tobacco Control
Story originated in 2019.
Lebanon: protecting people from tobacco smoke
Context
The initial ban on smoking in public places in Lebanon was declared in 1993, but inadequate enforcement and political events led to high smoking rates. The involvement of the tobacco industry in governmental decisions further hindered the development of a national policy. In 1998, the Ministry of Public Health established the National Tobacco Control Programme, with collaboration from WHO, and Lebanon ratified the WHO Framework Convention on Tobacco Control (FCTC) in December 2005. In 2009, a draft law was proposed to the Parliament after a period of political instability from 2005 to 2008. However, certain aspects of the draft were not aligned with the WHO FCTC, such as allowing smoking in designated sections of enclosed public places, implementing the ban gradually with a 5-year delay, and lacking fines for violations.
Initiative
A coalition comprising academic researchers, civil society and media came together to advocate for a comprehensive smoking ban in indoor public spaces, with no exceptions. They utilized local evidence highlighting the high prevalence of tobacco use and its health and economic impacts. In 2009, an intensive advocacy campaign was launched by various stakeholders to expedite the adoption of a comprehensive tobacco control policy. Concurrently, the National Tobacco Control Programme initiated a nationwide mass media campaign to raise awareness about the dangers of second-hand smoke. Public perception increasingly recognized tobacco use as a significant public health concern. A national survey demonstrated strong public support for smoke-free public places, with 94% agreeing that banning indoor smoking would benefit health and 82% believing it would be fair. In 2011, after persistent legislative efforts and challenges including interference from the tobacco industry, the Lebanese Parliament passed a new tobacco-control act (Law 174), making the country entirely smoke-free. The law encompassed a complete ban on smoking in enclosed public spaces like restaurants, cafes and public transport, accompanied by fines for non-compliance applicable to both establishment owners and smokers. A grace period and extensive mass media campaigns were implemented to promote awareness and facilitate the effective implementation of the law. The Ministry of Public Health collaborates with the ministries of interior, tourism and economy to enforce smoke-free policies.
Challenges and lessons learnt
The campaign's success hinged on the distinct roles played by each partner. The law was crafted with international guidance to incorporate global best practices, alongside advocacy efforts to garner public support. Nongovernmental organizations and civil society groups played a pivotal role in providing remarkable assistance for tobacco control initiatives. Despite challenges posed by interference from the tobacco industry and entrenched relationships between industry and policymakers, champions effectively aligned public health concerns with political will. The implementation of Law 174 faces hurdles due to recurrent political events that have compromised compliance and monitoring efforts. Insufficient staffing of inspectors has limited coverage across Lebanese regions. According to the WHO Report on the Global Tobacco Epidemic of 2019, compliance with smoke-free policies is relatively high in healthcare and educational facilities (8 and 9 out of 10), but lower in workplaces, government facilities and the hospitality industry (0 to 5 out of 10). Lebanon's smoking prevalence remains among the highest in the Region, primarily due to the lack of sustained funding for tobacco control activities.
Impact
The Ministry of Public Health's pivotal role in tackling tobacco-related matters has received acknowledgement, guaranteeing a widespread coalition encompassing various government sectors and ministries to enforce comprehensive tobacco control measures. Lebanon has taken a significant stride in tobacco control by implementing this law, although concerns persist regarding the tireless tactics and interference of the tobacco industry in impeding its execution.
Next steps
The Ministry of Public Health remains committed to preventing the initiation of smoking, particularly among youth, and reducing tobacco use across all demographics through the implementation of cessation programmes. Efforts will be made to minimize exposure to secondhand smoke and enhance public awareness regarding the detrimental effects of smoking and tobacco exposure. Lebanon is also actively combating the illicit trade of tobacco products.
References
MPOWER measures to reduce demand for tobacco
WHO Framework Convention on Tobacco Control
WHO Report on the Global Epidemic Tobacco 2019
Story originated in 2019.
Oman: enforcing bans on tobacco advertising, promotion and sponsorship
Context
Oman became a Party to the WHO Framework Convention on Tobacco Control (FCTC) in 2005, the second country of the Gulf Cooperation Council and 5th in the WHO Eastern Mediterranean Region to do so. Until 2013, collaboration among the National Tobacco Control Committee, including the Ministry of Information, Ministry of Commerce and Industry, and local municipalities, led to an unofficial prohibition on tobacco product advertising across various media platforms such as billboards, national newspapers, private and public radio, and national television broadcasts. This was achieved by denying permits for such commercial activities, which all media companies in Oman strictly adhered to. However, this informal ban did not cover point-of-sale advertisements and those found on individual tobacco packs. Furthermore, Oman lacked national legislation to completely ban tobacco advertising, promotion and sponsorship.
Initiative
In 2013, Oman took action to comply with Article 13 of the WHO FCTC by implementing a comprehensive ban on tobacco promotion. This included prohibiting discounts, giveaways, draws and scratch cards associated with tobacco products, as well as banning tobacco advertising, including point-of-sale advertisements. The National Coordination Mechanism actively advocated for these requirements in the National Tobacco Control Committee meetings and ensured their implementation. Two committee members, representing the Ministry of Commerce and Industry, introduced amendments to the products promotion regulations through Ministerial Decree No. 239 in December 2013, which explicitly banned all direct and indirect forms of tobacco product promotion. The decree clearly defined various forms of promotion and included punitive measures.
In 2015, another committee member successfully obtained Ministerial Decree No. 129 for 2015, which prohibited all direct and indirect discounts and sales on tobacco products. In 2016, the committee member from the Ministry of Information played a crucial role in issuing Ministerial Decree No. 42 for 2016, which banned all forms of tobacco advertising, including electronic media. However, the tobacco industry, through its retailers, resisted implementing the ban at points-of-sale, arguing that the ministerial ban only applied to published print media and television advertisements. To address this, the Ministry of Information amended Ministerial Decree No. 43 for 2018 to explicitly state a ban on all forms of advertising, wherever they are found. This settled the matter, resulting in the complete disappearance of tobacco product advertising, including at points-of-sale, throughout Oman.
Challenges and lessons learnt
Successful tobacco control efforts require concerted multisectoral collaboration and coordination. The ban on direct and indirect tobacco product advertising and promotion was communicated to all municipalities. However, achieving a comprehensive ban on tobacco advertising and promotion took Oman five years and required careful consideration of potential loopholes exploited by the tobacco industry, including its retailers. Continuous monitoring and follow-up by the National Coordination Mechanism are crucial for maintaining momentum in tobacco control. Despite these achievements, challenges remain. Cross-border tobacco advertising is a concern due to the accessibility of international media beyond national jurisdiction. Further legislative work is needed to address sponsorship and corporate social responsibility activities, which are currently restricted through mutual understanding between the National Tobacco Control Committee and targeted institutions.
Impact
The specific impact of the ban on tobacco advertising and promotion in Oman has not been measured. As the latest Global Youth Tobacco Survey was conducted in 2016, further research is required to assess whether these bans have resulted in a decrease in the proportion of young people who visit points-of-sale and are exposed to tobacco advertising or promotions (34.5%), own items with cigarette brand logos (9.2%), or have received free cigarettes from tobacco company representatives (7.1%). However, compliance data collected in the country indicate that the bans on direct and indirect tobacco advertising are effectively enforced, with a high level of compliance (7 to 8 out of 10), according to the WHO Report on the Global Tobacco Epidemic of 2019. Currently, all forms of tobacco advertising, promotion and discounts have been eliminated throughout Oman. This is expected to contribute to a reduction in tobacco use among both adults and youth, fulfilling Oman's obligations under the WHO FCTC.
Next steps
It is important to establish a mechanism that ensures the ongoing enforcement of these tobacco control measures, as well as any future initiatives. Similar strategies employed for implementing excise taxes on tobacco products and introducing pictorial health warnings in Oman and other countries of the Gulf Cooperation Council should be utilized.
References
MPOWER measures to reduce demand for tobacco
WHO Framework Convention on Tobacco Control
WHO Report on the Global Tobacco Epidemic 2019
Story originated in 2019.
Iraq: warning about the dangers of tobacco
Context
Iraq became a Party to the WHO Framework Convention on Tobacco Control (FCTC) on 17 March 2008. In line with Article 12 of the WHO FCTC, a tobacco control law was introduced in 2012, with a primary focus on promoting public health awareness about the dangers associated with tobacco use. Annually, a national tobacco control plan is implemented to enhance public knowledge and foster negative attitudes towards tobacco consumption.
To address existing gaps and challenges, such as the difficult implementation of the tobacco control law due to current conditions in the country, interference from the tobacco industry and the widespread availability of affordable tobacco products, the Ministry of Health has developed a comprehensive national campaign against smoking. The objective of this initiative aligns with the guidelines outlined by the WHO FCTC, aimed at bridging the gaps and addressing the challenges faced by Iraq in tobacco control.
Initiative
In order to implement the national tobacco control plan of 2018 and the strategy for prevention and control of noncommunicable diseases from 2018 to 2023, and in line with the recommendations of the National Committee of Tobacco Control held in the Ministry of Youth and Sports, a comprehensive national campaign against smoking was launched for a continuous three-week period in October and November 2018. This campaign, in line with the guidelines of the WHO FCTC, specifically targeted the millions of individuals visiting the Holy City of Karbelaa during a religious event, aiming to raise awareness of the health risks associated with tobacco, particularly waterpipe smoking, for both smokers and non-smokers due to secondhand smoking.
The campaign was carried out in collaboration with religious leaders, and various awareness materials such as posters, videos, etc. were produced and printed to be distributed to the visitors through mobile health teams, involving the participation of most health directorates. Additionally, the Ministry of Health arranged a dedicated section within the 45th National Baghdad Exhibition to spread health awareness among the general public. This involved the use of diverse health education materials and direct face-to-face interactions and interviews with the public.
Furthermore, several health directorates organized seminars and educational lectures on the harmful effects of tobacco, both within and outside health centers, and conducted field visits to schools participating in the anti-smoking schools project. Many ministries, health directorates, and nongovernmental organizations participated in this initiative, contributing to the provision of free exhibition space, printing educational materials for the campaign, and offering symbolic gifts featuring the logo of the National Tobacco Control Committee. Notable participating ministries and authorities included the ministries of interior, housing and development, commerce, industry, culture, finance and the National Tax Authority.
In a first for Iraq, a carbon monoxide analyzer machine was utilized at the exhibition to support smoking cessation services. Smokers visiting the exhibition displayed a keen interest in measuring the toxicity levels resulting from their tobacco use. Despite the unavailability of necessary medications such as Bupropion and nicotine replacement therapies in healthcare facilities, smokers expressed a strong willingness to purchase them from the local market in order to quit smoking.
Challenges and lessons learnt
The success of this initiative can be attributed to the extensive media coverage received, as well as the participation of influential policymakers and notable figures including the Minister of Health's consultant, the Minister of Communication, the Deputy Minister of Commerce, the Director General of Traffic, the Director of Baghdad's Traffic and several prominent media and cultural celebrities. The media attention shed light on tobacco control activities and paved the way for future collaborations in this field. Additionally, the public's keen interest in availing smoking cessation services and staying updated on developments in this area was noteworthy. The tobacco control section of the exhibition received a certificate of appreciation from the General Director of Exhibitions and Commercial Services in the Ministry of Commerce for its active participation in the 45th National Baghdad Exhibition.
However, several challenges were encountered during the implementation of this initiative. The tobacco industry made attempts to promote their products, taking advantage of the large number of visitors to the national exhibition. Nevertheless, these violations were identified as tobacco promotion and the exhibition coordinators took appropriate actions. Another obstacle was the lack of availability of nicotine replacement therapy in smoking cessation services, which hindered efforts to encourage more smokers to quit. Originally, it was planned for a pharmaceutical company to participate in the event and showcase their nicotine replacement therapy products to smokers, offering free samples to incentivize smoking cessation. However, this was not possible due to the products not being registered with the Ministry of Health, a lengthy process. Furthermore, the challenging political and social conditions in the country limited the ability to carry out similar initiatives in other provinces of Iraq.
Impact
The impact of the initiative was evident in the heightened health consciousness among the general public regarding the detrimental effects associated with tobacco consumption, with particular emphasis on the younger generation and adolescents. It successfully fostered active engagement from the public, as well as healthcare professionals, in promoting health awareness. Moreover, decision-makers were equipped with enhanced knowledge and understanding to adopt tobacco control measures. The initiative also exerted pressure on both governmental and nongovernmental organizations to implement tobacco control activities through various means such as seminars, educational lectures and other effective approaches.
Next steps
Future actions involve the annual repetition of mass media campaigns on tobacco hazards, as outlined in the National Tobacco Control Plan issued by the Ministry of Health. These campaigns will involve a wider range of state institutions, thereby strengthening health awareness about the detrimental effects of tobacco through national and international events. Additionally, periodic educational seminars and symposiums will be conducted outside of healthcare facilities. It is imperative to enhance smoking cessation services in primary healthcare settings, ensuring the provision of necessary resources such as C0-analyzers, nicotine replacement therapy, hotlines and other relevant resources. Efforts will be made to strengthen and foster collaboration with governmental and nongovernmental organizations, with the active participation of decision-makers in upcoming tobacco control activities and events.
References
MPOWER measures to reduce demand for tobacco
WHO Framework Convention on Tobacco Control
Story originated in 2019.
