The Saudi Dental Journal (2017) xxx, xxx–xxx
King Saud University
The Saudi Dental Journal
www.ksu.edu.sa
www.sciencedirect.com
REVIEW ARTICLE
Accomplishments and challenges in tobacco control
endeavors – Report from the Gulf Cooperation
Council countries
Kamran Habib Awan a,b,*, Quratul Ann Hussain a, Shahrukh Khan c,
Syed Wali Peeran d, Magdy Khaled Hamam a, Emad Al Hadlaq a,
Hamad Al Bagieh a
a
Department of Oral Medicine & Diagnostic Sciences, College of Dentistry, King Saud University, Riyadh, Saudi Arabia
College of Dental Medicine, Roseman University of Health Sciences, South Jordan, UT, United States
c
Centre of Rural Health, Faculty of Health, University of Tasmania, Hobart, Tasmania, Australia
d
Department of Periodontics, Faculty of Dentistry, Sebha University, Sebha, Libya
b
Received 25 May 2017; revised 2 August 2017; accepted 3 August 2017
KEYWORDS
Tobacco control;
Public policy;
GCC;
Cessation;
Surveillance and monitoring
Abstract Objectives: To review the tobacco governance and national responsibility for control,
and existing countering measures to reduce the tobacco use among the Gulf Cooperation Council
(GCC) member states.
Methods: We reviewed the data in regards to tobacco control efforts and difficulties encountered
during implementation of the policies for all the GCC member states from the respective country
profile in the WHO report on the global tobacco epidemic. Also, we utilized the measures outlined
in the FCTC’s MPOWER package to not only assess the degree of national commitment, but also
compare it against the level of significance that the legislatures give to this matter.
Results: We observed that there have been genuine advancements towards tobacco control in the
GCC member states over the past few years. All the countries except Bahrain have national offices
committed to tobacco control and 5 nations (excluding Oman) have dedicated support services for
smoking cessation accessible to the general public. Similarly, majority of the member states have
implemented a national-level ban on tobacco advertisement through national media cells as well
as free dissemination of marketing material.
* Corresponding author at: College of Dental Medicine, Roseman University of Health Sciences, South Jordan, UT 84095, United States.
E-mail address: kamranhabibawan@gmail.com (K.H. Awan).
Peer review under responsibility of King Saud University.
Production and hosting by Elsevier
https://doi.org/10.1016/j.sdentj.2017.08.003
1013-9052 Ó 2017 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article in press as: Awan, K.H. et al., Accomplishments and challenges in tobacco control endeavors – Report from the Gulf Cooperation Council
countries. The Saudi Dental Journal (2017), https://doi.org/10.1016/j.sdentj.2017.08.003
2
K.H. Awan et al.
Conclusion: Application and implementation of measures outline in the MPOWER package,
formulation and enforcement of sturdy laws on tobacco control, and development of infrastructure
and trained workforce are fundamental to manage and reinforce tobacco control measures in the
GCC region.
Ó 2017 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University. This is
an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Contents
1.
2.
3.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1. Governments’ actions in controlling the tobacco endemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2. Prevalence and tendency of tobacco use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Introduction
Tobacco use is one of the most preventable causes of disease
and premature death globally (US Department of Health
and Human Services, 2004). The general and oral health
related adverse effects of tobacco use are well documented
(Awan, 2011; Warnakulasuriya, 2005; Warnakulasuriya
et al., 2005; Palmer et al., 2005). In spite of the recent advances
in diagnosis and treatment, tobacco-related morbidity and
mortality is on the rise, accounting for nearly 6 million deaths
annually from both direct and indirect use (Mackay and
Eriksen, 2002). The best approach to control this threat is by
concentrating efforts towards ending its use, by both educating
users as well as healthcare professionals (Awan et al., 2015).
The need to take the assertive measures towards tobacco cessation is reinforced by various studies that have shown numerous advantages of these measures (US Department of Health
and Human Services, 1990; Wu and Sin, 2011).
Many countries are focusing on the fight against tobacco.
In this paper, we present the efforts taken by the Gulf Cooperation Council (GCC) member states, a region that harbors
tobacco-related mortality rates of 2% and 12% among females
and males respectively (Tobacco free initiative [website], 2015).
The GCC is a political and economic association of 6 member
states, including Bahrain, Kuwait, Oman, Qatar, Saudi Arabia
and the United Arab Emirates (UAE). All the GCC member
states intrinsically rely upon expatriates for their workforce,
with the share of foreign workers in some member states
(Qatar and UAE) reaching as high as 80–90% (Integration,
2010). This has significant complications for the planning
and implementation of an array of policies, including those
related to general public health.
Tobacco is a menace that affects both the adults as well as
the youth. Data from the Global Youth Tobacco Survey
(GYTS) show alarmingly high percentages of adolescent current smokers in the GCC member states (Data, 2015). In the
UAE (2005), 8% of young people were identified as smokers
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and 28.8% as utilizing other tobacco-related products. In
Saudi Arabia (2007), while 6.7% of adolescents were smokers,
a further 11.9% utilized other tobacco-related products.
Almost similar figures have been reported among youths in
Bahrain (2002), Qatar (2007) and Kuwait (2009), where the
prevalence of cigarette smoking were 10.6%, 12.2%, 6.5%
and 3.9% respectively, and of those currently using other
tobacco products were 15.3%, 11.8%, 15.6% respectively.
The minimum prevalence was reported in Oman (2010), where
around 2% of youth were either using cigarettes (1.8%) or
other tobacco-related products (2.2%) (Data, 2015).
In the GCC, tobacco control endeavors began in January
1979, when Saudi Arabia presented a preliminary scientific
proposal at the 6th GCC Health Ministers’ Council Conference on fighting smoking in the region. The WHO Framework
Convention on Tobacco Control (FCTC) treaty (Framework
Convention, 2015), has since been signed by the majority of
the GCC member states (Kuwait, Qatar, Saudi Arabia and
UAE), however, every single member state has endorsed it.
Encouragingly, all member states now possess a nationallevel agency or specialized unit focused towards tobacco control (Data, 2015). In order to assist the member states in fulfilling their WHO FCTC commitments, the WHO in 2008
presented the MPOWER package of 6 evidence-based tobacco
control measures that are demonstrated to decrease tobacco
usage (Table 1). The MPOWER measures offer useful support
to decrease the demand for tobacco through implementation
of viable strategies at national level. Although the measures
outlined in the MPOWER package mainly concentrate on
reducing the demand, the WHO acknowledge the significance
of supply-side and is fully committed in employing the relevant
measures defined in the FCTC.
The aim of this review paper is to present an overview of
the difficulties confronted by the GCC member states in implementing the tobacco-control measures. In addition, it also
highlights the endeavors put to date by the GCC governments
in controlling the tobacco epidemic. By doing so, it not only
Please cite this article in press as: Awan, K.H. et al., Accomplishments and challenges in tobacco control endeavors – Report from the Gulf Cooperation Council
countries. The Saudi Dental Journal (2017), https://doi.org/10.1016/j.sdentj.2017.08.003
Accomplishments and challenges in tobacco control endeavors
3
Table 1 WHO MPOWER package of 6 evidence-based tobacco
control measures.
addresses the accomplishments and disappointments, but also
proposes a way forward for the GCC member states in their
fight against tobacco.
2. Methods
Data was collected from all the six member states of the GCC
in regards to their efforts towards tobacco control and difficulties encountered during implementation of the policies. Data
for each individual GCC member state was obtained from
the respective country profile in the WHO report on the global
tobacco epidemic. (WHO report on the global tobacco
epidemic, 2015) The WHO tobacco report was selected as
the primary source because it has the most complete information on all countries in our analysis, with the most systematic
categorization of tobacco control legislation status as of 2015.
In addition, detailed automated online search of PubMed,
Medline, EMBASE and ISI Web of Science was also performed using the following key words and Boolean operators;
‘‘tobacco”; ‘‘smoking”; ‘‘Gulf Cooperation Council”. This was
performed to ensure that the most recent information on any
changes in tobacco legislation or control measures is recorded.
To explore the indices of national obligation towards safety
of the general public and controlling the tobacco pandemic in
the GCC member states, we utilized the measures outlined in
the FCTC’s MPOWER package to not only assess the degree
of national commitment, but also compare it against the level
of significance that the legislatures give to this matter.
3. Results
The GCC member states have shown a noteworthy governmental dedication towards tobacco control from an authoritative point of view, (Zain, 2012; Reini, 2009; Olayiwola, 2013;
Khoja and Hussein, 2004) however, more is still required, especially towards educating the general public and establishing
further state funded training and research centers. (Awaisu
et al., 2013; Mahfoud et al., 2012) Maintaining such responsibility is critical to carry on the momentum that many of these
nations are currently enjoying.
3.1. Governments’ actions in controlling the tobacco endemic
Since 2010, each of the 6 GCC member states has a particular
government objective with respect to tobacco control. Table 2
shows the summary of MPOWER measures taken by each
GCC member states (extracted from WHO updated country
profiles and published in the WHO report on the global
tobacco epidemic, 2015).
All the countries except Bahrain have national offices committed to tobacco control and 5 nations (excluding Oman)
have dedicated support services for smoking cessation accessible to the general public (with costs either in part or completely
secured). The majority of the member states have implemented
a national-level ban on tobacco advertisement through
national media cells as well as free dissemination of marketing
material. Moreover, a few countries (Saudi Arabia and UAE)
have also banned smoking in some public places, including
government, health-care and educational facilities.
In spite of the above-mentioned governmental progress,
there are certain areas that show lack of dedication towards
tobacco control or even relapse in them. One such example
is the reduction in taxation on tobacco products; 4 of the
GCC member states (Bahrain, Oman, Saudi Arabia and
UAE) reduced the tax percentage on purchase of cigarettes
by 2–3% between 2008 and 2010. It is vital for the government
of these countries to understand the negative impact such
arrangements may have on public accessibility to tobacco,
and therefore efforts should be made to increase the taxation
percentage as opposed to decreasing it, regardless of the supplementary tobacco control measure.
3.2. Prevalence and tendency of tobacco use
A wide range of research has been carried out in the GCC
region looking into the prevalence, mortality and morbidity
in relation to tobacco use. Our review of the published literature identified 19 studies, of which 6 studies were observed to
be pertinent. (Al-Hamdan et al., 2009; Moh’d Al-Mulla et al.,
2008; Hamadeh, 1998; Al-Hashel et al., 2012; Fahdil, 2007; AlAmari, 2011) The excluded studies were either irretrievable
(n = 2), irrelevant (n = 4) or duplicates (n = 7). Among pertinent studies, 3 focused on the tobacco related issues in the
GCC member states collectively, (Al-Hamdan et al., 2009;
Moh’d Al-Mullaet al., 2008; Hamadeh, 1998) while 2 studies
addressed the relevant issues in Bahrain, (Al-Hashel et al.,
2012; Fahdil, 2007) and only 1 study was carried out in the
UAE (Al-Amari, 2011).
In a study, the authors investigated the prevalence of cancer
from 1998 to 2001 in the GCC member states. (Al-Hamdan
et al., 2009) They concluded that there is a plausible relation-
Please cite this article in press as: Awan, K.H. et al., Accomplishments and challenges in tobacco control endeavors – Report from the Gulf Cooperation Council
countries. The Saudi Dental Journal (2017), https://doi.org/10.1016/j.sdentj.2017.08.003
4
K.H. Awan et al.
Table 2
Tobacco control related measures in the Gulf Cooperation Council countries14.
Programs
Bahrain
Kuwait
Oman
Qatar
Saudi
Arabia
UAE
Specific government goals towards tobacco control at national
level
Establishment of a national body to provide technical support
WHO FTCT status (year)
Signed
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
(2003)
Yes
(2006)
No
Yes
Yes
No
Yes (2004)
Yes
(2005)
No
No
Yes
Yes
(2003)
Yes
(2004)
No
Yes
Yes
Yesa
Yes
Yes
Yes
(2004)
Yes
(2005)
Yesb
Yes
Yes
Yes
Yes
Yes
Yesd
Fullyh
34
No
No
No
No
No
31
Yes
Yes
Yes
Yese
Fullyi
33
Yes
Yes
Yes
Yesf
Partially
29
Yes
Yes
Yes
Yesg
Partially
29
Endorsed, or similar legislation
Yes
(2007)
No
Yes
Yes
Public places with smoke-free legislation
National law requires fines for smoking
Legal requirement of tobacco products showing health
warnings
Bans implemented on tobacco advertising, promotion and sponsorship
Electronic media cells (TV, radio)
Yes
Print media cells (newspapers, magazines)
Yes
Free distribution of promotional material and packages
Yes
Availability of smoking cessation services
Yesc
Provision of free of cost smoking cessation services
Fully
Total taxes on the most popular brand of cigarettes (% of retail 29
price)
Yes (2005)
a
In government, health-care and educational facilities only.
In health-care and educational facilities only.
c
In most health clinics or primary-care facilities, in some hospitals, in some offices of health professionals but not in the community.
d
In most health clinics or primary-care facilities, in some hospitals, in some offices of health professionals and in the community.
e
In only some health clinics or primary-care facilities, in some hospitals, in some offices of health professionals but not in the community.
f
In only some health clinics or primary-care facilities, in some hospitals, in some part of the community, but not in offices of health
professionals.
g
In only some health clinics or primary-care facilities, in most hospitals, in some offices of health professionals and in some parts of the
community.
h
Except in the community, where it is only partially covered by national insurance.
i
Information on national financial coverage for smoking cessation support is only for hospitals (data not available for health clinics and
primary-care facilities).
b
ship between an extended history of smoking in Bahrain and
the higher prevalence of lung cancer in Bahrain than other
GCC member states.
Waterpipe smoking is a growing concern in the GCC
region. A study that evaluated tobacco utilization among
GCC member states using Global Youth Tobacco Survey
(GYTS) data reported a higher incidence of cigarette smoking
with an even higher incidence of waterpipe smoking. (Moh’d
Al-Mulla et al., 2008) They also reported that vulnerability
to initiate waterpipe smoking was higher among never smokers
group. These results are worrying as they indicate a likely
increase in the prevalence of tobacco-related diseases and their
associated mortality in the GCC member states. One should
note that the amount of nicotine and tar found in one ‘head’
of waterpipe is almost equivalent to the amount found in 10
cigarettes (Rawaf et al., 2013; Shihadeh and Saleh, 2005).
Studying all the GCC member states collectively, Hamadeh
insinuated the formerly stated hazard of increased incidence
and potential issue of tobacco, (Hamadeh, 1998) and accentuated the admirable efforts implemented by the uniform body
of the GCC Health Ministers’ Council (Tobacco control
program [website], 2015) and the early acknowledgment of
the tobacco-related problem.
In a study in Bahrain, smoking practices and potential reasons for failure in smoking cessation were evaluated among
250 adult Bahrainis and non-Bahrainis (Al-Hashel et al.,
2012). The authors reported that more than one-third of the
smokers (33%) stated tobacco craving as the primary reason
for their inability to quit smoking. Other reported reasons
included satisfaction in smoking (24%) and nicotine withdrawal symptoms (11%). Fadhil in his review paper to highlight the efforts for tobacco control in Bahrain presented a
distinct and comprehensive picture of tobacco control endeavors in the country (Fahdil, 2007). The author reported that
lack of implementation of laws and decrees as the main barriers in the tobacco control efforts and highlighted the grave
need for the development of smoking cessation programs as
part of the primary health care setup.
A cross-sectional study carried out among 288 medical doctors from the Department of Health and Medical Services in
Dubai, UAE, reported a lack of smoking-cessation skills
among them (Al-Amari, 2011). The authors recommended that
there is a need for the improvement of smoking-cessation
specific skills among healthcare professionals along with the
development of smoking cessation programs that ensure participation of the physicians to reduce tobacco usage among
the general public.
4. Discussion
The paper reports a pragmatic evaluation of a multifaceted
analysis of the present situation of tobacco use among the
Please cite this article in press as: Awan, K.H. et al., Accomplishments and challenges in tobacco control endeavors – Report from the Gulf Cooperation Council
countries. The Saudi Dental Journal (2017), https://doi.org/10.1016/j.sdentj.2017.08.003
Accomplishments and challenges in tobacco control endeavors
GCC member states; administration and national obligation
towards tobacco control; and current mediation systems
employed to lessen the utilization of tobacco among the community. Furthermore, it analyses organized policy-oriented
measures in accordance with the FCTC’s MPOWER package
that symbolize government activities to reinforce, execute and
oversee tobacco control programs and to address the developing endemic of tobacco use.
Regardless of the endeavors and triumphs in the field of
tobacco control by the GCC member states, there still remain
numerous obstacles that need to be crossed to achieve goals.
These obstacles can be external in the form of lack of defiance
to campaigning and pressure employed by the tobacco companies (Zain, 2012), or internal in the form of intermittent or lack
of supervision of the tobacco-related legislation and partial
execution of tobacco controlling endeavors (WHO report on
the global tobacco epidemic., 2013). Considering the recent
advancements in tobacco control by the GCC member states,
it is quite evident that further efforts are needed particularly
towards the implementation of legislation and management
of current, well-organized strategies. Furthermore, development of human resources in terms of providing them training
and infrastructure as well as commitment of policy makers
towards public health is vital.
One type of tobacco use that has been overlooked so far,
both in terms of policy making and generating public awareness despite its increasing popularity among youth is waterpipe
smoking (WPS). Policies recommended by the FCTC were
mainly based on evidence of controlling cigarette smoking,
and may not be applicable on WPS due to the unique nature
of the latter. In comparison to cigarettes, waterpipes come in
different shapes and sizes, are unmovable and often shared.
Most of the waterpipe tobacco products available in the
GCC region either completely lack warning labeling practices
or have misleading descriptors such as 0% nicotine, 0% tar
(Nakkash and Khalil, 2010). Moreover, policy makers have
been casual in implementing indoor smoking bans on waterpipe bars and cafes despite the evidence on emission of harmful
compounds in WPS (Daher et al., 2010; Maziak et al., 2008;
Awan et al., 2017; Awan et al., 2016).
From a practical perspective, a range of measures and
responsibilities are available that these nations can initiate to
fast track and amplify the incentive for commitment. For
instance, the GCC member states may set up a national-level
reference body that exclusively focuses on prevention of
tobacco use and protection against tobacco-related health hazards. Moreover, and in accordance with the cumulative public
health endeavors, a revised commitment may be directed
towards empowering group activities and promotions, especially at work environments. This proposal may be further
reinforced with the establishment of smoking cessation facilities. These facilities should not only train medical or paramedical staff, but also employ the aptitude of the general public and utilize them as smoking cessation councilors, henceforth increasing the workforce to help curtail tobacco usage.
5. Conclusion
Tobacco control in GCC member states has seen noticeable
growth in recent years. However, there are certain areas that
need overhauling; restructuring of delivery mechanism of the
5
smoking cessation services and establishment of international
standard smoking cessation facilities. Application and implementation of FCTC and development of powerful and effective tobacco control legislations are imperative to support
and fortify tobacco control efforts in the region.
Conflict of interest
The authors declared that there is no conflict of interest.
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Please cite this article in press as: Awan, K.H. et al., Accomplishments and challenges in tobacco control endeavors – Report from the Gulf Cooperation Council
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