Navigating Challenges in Tobacco Control Policy and Legislation: Operational Strategies for Success

Smoking is a leading contributor to fatalities and chronic illnesses on a global scale and poses a significant challenge in the modern era (1). In the 20th century, tobacco use claimed the lives of 100 million individuals, exceeding the combined casualties of both World War I and II. If current tobacco consumption trends continue, it is projected that one billion deaths will be attributed to tobacco-related causes in the 21st century (2). Over 80% of these deaths occur in low- and middle-income countries (3).

According to World Health Organization (WHO) estimates, in 2015, 18% of deaths from non-communicable diseases in Europe were attributed to tobacco use (4). Tobacco use accounts for 9% of the total disease burden, 22% of the cancer burden, and 13% of all attributable deaths (5). In Iran, tobacco was identified as the fourth-leading risk factor for attributable disability-adjusted life years (DALYs), following high blood pressure, high Body Mass Index, and high fasting plasma glucose (6). The latest WHO report estimates that smoking prevalence among Iran’s population aged 15 and older is 11.8%, with rates of 22.1% in men and 1.3% in women (7). A recent study conducted in Iran revealed that smoking caused 6,623 cancer-related deaths, 808.80 years of life lost, and incurred productivity costs of 58,301,983$ (8).

Smoking is associated with various diseases, including heart and lung conditions, chronic respiratory illnesses, various cancers, diabetes, autoimmune disorders, and osteoporosis. Reducing tobacco consumption is essential to alleviating the impact of non-communicable diseases, which account for 71% of global mortality (9). In addition to its adverse health consequences, significant financial resources are allocated annually to treat illnesses resulting from tobacco consumption. World Health Organization reports indicate that health systems worldwide incur a financial burden exceeding 10$ billion each year due to tobacco-related diseases (10). The economic impact of tobacco use amounts to an estimated cost of 136.9$ billion per year, along with a noteworthy decrease in tobacco excise revenue of 13.3$ billion (11).

Despite national restrictions on tobacco sales to minors, approximately 25% of individuals under 18 years old engage in tobacco use, with 12.6% using more than two varieties of tobacco products (12).

Smokers are less productive due to the increased incidence of disease, and those who die prematurely deprive their families of much-needed income. Tobacco use and poverty are inextricably linked, as it exacerbates poverty and hinders economic development (13). The significant impact of the global tobacco crisis on health and the economy has underscored the importance of prioritizing tobacco control as a crucial public health initiative. Timely and decisive action in tobacco control is essential for nations striving to achieve the 2030 sustainable development goals (14). Implementing evidence-based tobacco control measures not only enhances life expectancy but also reduces healthcare expenses (15). Therefore, enforcing comprehensive tobacco control policies based on sound evidence can significantly alleviate the burden of smoking-related diseases (16).

In 1996, the government endorsed a directive titled "Guidelines for Reducing Tobacco Consumption", which consisted of six articles aimed at curbing tobacco use in Iran; however, it was never implemented (17). Subsequently, a comprehensive national law for tobacco control was ratified with 20 articles and seven notes during a public session of the Islamic Council on September 15, 2006 (18).

Despite the existence of robust tobacco-related laws in Iran, experts indicate that controlling tobacco use remains a challenge. This difficulty stems from influential economic and political entities that have emerged from cigarette production and sales. The complex nature of tobacco control is attributed to factors such as the involvement of transnational players, disparities in the distribution of benefits and costs within the tobacco industry, the widespread economic gains associated with tobacco, health consequences, and the involvement of multiple stakeholders with vested interests in the tobacco business (19).

As stated in the comprehensive tobacco control law of Iran, individuals under 18 are prohibited from purchasing or selling tobacco, smoking in enclosed public places, or engaging in any form of tobacco advertising (20, 21). The inclination towards tobacco use is a significant societal issue, representing a complex human behavior that necessitates exploring the fundamental community aspects. Despite extensive policy-making and legislative efforts aimed at tobacco control in Iran, the prevalence of tobacco use continues to rise.

Therefore, it is essential to identify the challenges associated with policy formulation and legislation and propose effective solutions for tobacco control. This study aimed to explore the challenges faced in formulating and enacting tobacco control policies and legislation and to offer solutions for their effective implementation.

The analysis of the interviews regarding the challenges in tobacco control policy and legislation in Iran resulted in the extraction of three main themes and 43 sub-themes, as presented in Table 2. Additionally, to identify implementation solutions addressing these challenges, two main themes and 16 sub-themes were extracted and detailed in Table 3.

This qualitative study aimed to identify the challenges in tobacco control policy-making and legislation in Iran and to propose operational solutions to improve the policy-making process. Participants in the study highlighted several challenges related to tobacco control policymaking and the legislative process itself. The development and enactment of tobacco control policies can lead to decreased tobacco consumption, improved public health outcomes, reduced incidence of tobacco-related illnesses, increased awareness regarding the harmful effects of tobacco, and the establishment of smoke-free environments for non-smokers. However, research has revealed various challenges in Iran, including the misalignment of national laws with global tobacco control standards, the complex and diverse nature of tobacco control discussions, insufficient research in the Iranian tobacco sector, limited media engagement, and conflicting interests in the policymaking processes related to tobacco control.

In line with the present study, Kusuma et al. indicated that the absence of a multisectoral national tobacco control policy in Indonesia, due to unclear power and responsibilities among stakeholders, was a key factor in halting the progress of tobacco control initiatives (24). Similarly, the findings of Kramer et al. revealed that, contrary to the goals of tobacco control, certain adverse outcomes were observed, with the Department of Agriculture supporting the tobacco industry through regulations that protect domestic markets. The failure to establish agricultural schemes that assist tobacco farmers in transitioning to alternative crops and the continued focus on tobacco production reflect a reluctance to engage in comprehensive tobacco control efforts (25). Despite having established comprehensive tobacco control legislation, Iran continues to struggle with enforcement and the influence of the tobacco industry, necessitating a more coordinated and robust approach to align its efforts with international best practices.

Willemsen et al. identified budget shortages, lack of coordination in scientific research, and the absence of comparable surveillance data across Europe as significant policy challenges in the field of tobacco control (4). Furthermore, the European Union has not allocated sufficient funding for tobacco control research (26). Countries with less favorable political environments and lower budgets for tobacco control research face the greatest difficulties in implementing framework convention on tobacco control (FCTC) measures (4). By allocating an appropriate budget for tobacco control in the national annual budget, earmarking dedicated funds for tobacco research, and leveraging scientific approaches and insights from successful tobacco control policies in other countries, Iran can effectively advance its tobacco control efforts.

The findings of the present study highlighted inadequate media influence and the promotion of smoking through television and movies as significant challenges, aligning with the studies conducted by Islami et al. and Nasirzadeh et al. Islami et al. noted that cautionary messages from community media regarding tobacco control have been significantly overlooked, while Nasirzadeh et al. found that many young individuals frequently encounter tobacco advertisements on television and in public spaces (10, 27). In contrast, Al-Kuwari et al. highlighted Qatar’s effective strategy of banning all direct and indirect advertising of tobacco products and sponsorships by the tobacco industry (28).

To address these challenges in Iran, collaboration between the Ministry of Culture and Islamic Guidance and the Iranian Broadcasting Organization is essential. This partnership could focus on producing impactful content that educates the public about the harmful effects of tobacco. Specific actions could include developing educational programs, creating public service announcements, and integrating anti-tobacco messages into popular media.

Additionally, enforcing stricter laws on tobacco advertising, launching awareness campaigns about the health risks of smoking, and increasing oversight by the Ministry of Guidance could further mitigate these issues. Depicting tobacco use in an unappealing manner in films and media content would also help discourage smoking and reduce the appeal of tobacco products among viewers.

Iran’s tobacco control policy is currently facing significant challenges due to various factors. The rise of illicit tobacco products, evolving consumption patterns among different age and gender groups, and the increasing prevalence of cigarette and hookah use in traditional dining establishments complicate efforts to manage tobacco use effectively. Additionally, new media campaigns promoting flavored tobacco products have exacerbated these challenges.

Study by Flynn et al. highlights that marketing strategies targeting youth, such as selling tobacco products near schools, advertising in youth-oriented media channels, and positively portraying cigarettes and flavored tobacco, have contributed to increased substance use among young individuals (29). To address these issues, it is crucial for Iran to strengthen its tobacco control measures, including implementing stricter regulations on advertising and marketing, particularly those targeting younger demographics.

The participants in this study stated that Iran’s poor economic situation and high unemployment rates have hindered tobacco control policies. Similarly, Habibpour’s study found that individuals from lower socioeconomic backgrounds are more likely to turn to tobacco consumption as a coping mechanism (30). To address the economic and employment challenges affecting tobacco control policies in Iran, it is recommended to implement targeted educational campaigns, provide accessible cessation support, offer economic incentives, and develop social and economic support programs.

Tobacco use is on the rise among women and adolescents. In 2016, the STEPS study reported that, on average, 14% of the Iranian population consumed tobacco (31). Consistent with our findings, Ravaghi et al. found that the Ministry of Health of Iran, together with relevant agencies, has developed and implemented a wide range of anti-tobacco mass media campaigns focusing on hookah consumption among youth and women. Despite these efforts to raise public awareness, the trend of tobacco consumption has not decreased (32).

In Japan, tobacco control measures consist of four key elements: Banning tobacco use in public areas, government buildings, taxis, and schools. Additionally, they have implemented a reward system for youths, especially girls, who successfully quit smoking, which has proven to be beneficial (33). In the United States, high taxes on tobacco, family smoking prevention laws, warning images on tobacco packaging, and eliminating chocolate flavors have contributed to a decrease in tobacco consumption (34).

According to Nasirzadeh et al., over 60% of tobacco users obtained their products from stores and shops, highlighting non-compliance with laws prohibiting tobacco sales to individuals under 18 as a factor contributing to adolescents’ increased access to tobacco (10). Currently, Iran has implemented laws prohibiting smoking in public places and has increased taxes on tobacco products. However, additional measures are needed, such as developing incentive programs for young people who successfully quit smoking and implementing strategies to enhance public awareness about the dangers of tobacco use. By adopting successful global practices, such as comprehensive media campaigns and stricter enforcement of age restrictions on tobacco sales, Iran can further strengthen its tobacco control efforts and reduce consumption rates among vulnerable populations.

The present research highlights that one of the most significant challenges in policymaking is the inadequacy of punitive measures related to tobacco use, as mentioned by Islami et al. (27). Additionally, the study’s findings indicate that organized tobacco smuggling in Iran hinders the enforcement of tobacco control laws and regulations. Heydari et al.’s research identified Iran and Iraq as primary destinations for tobacco smuggling in the Eastern Mediterranean region (35).

Furthermore, Muller and Wehbe emphasized that tobacco trafficking is a serious issue in the United States, particularly endangering young individuals. The availability of low-priced cigarettes in Latin America facilitates the initiation of smoking among youth using their own funds (36). Similarly, Willemsen et al.’s study in Europe noted that certain countries have utilized the EU-wide traceability system to combat illicit trade and have implemented strategies to ban flavored tobacco (4). The inadequacy of punitive measures in Iran highlights the need for innovative and operational solutions, such as implementing a comprehensive system of fines and penalties for violations of tobacco laws, along with establishing a robust monitoring framework to ensure compliance.

According to the participants, a key obstacle in enforcing tobacco control laws in Iran is taxation policies. Consistent with the present study, the 2017 WHO report indicated that Iran ranks the lowest among 22 countries in the Eastern Mediterranean region in terms of tobacco tax rates (20%), following Afghanistan, Somalia, Libya, and the United Arab Emirates (37).

Studies conducted in South Korea Durkin et al. by Do and Farooqui and found that increasing tobacco taxes, coupled with mass media campaigns and health promotion laws, effectively reduced smoking among young people, with prevalence dropping from 17.7% to 8% (38, 39). Similarly, in Indonesia, Egbe et al. found that implementing regulations to increase the base price of cigarettes and indirect tobacco tax led to significant improvements in tobacco control (40).

It appears that introducing higher tobacco taxes and strengthening consumption regulations, along with awareness campaigns to educate the public, could lead to more effective tobacco control in Iran.

In line with this study, Jongenelis’s research in Australia proposed several tobacco control strategies, including banning financial support to political parties, holding the industry accountable for the harm it causes, and requiring the government to fulfill its obligations under the FCTC (11). Similarly, Iran should enhance enforcement mechanisms for existing laws, increase public awareness campaigns tailored to youth and women, and establish community engagement programs that promote tobacco cessation. By integrating these strategies, Iran can create a more effective framework for combating tobacco use and protecting public health.

This study, like other research studies, had some limitations. Due to the political nature of tobacco issues, some participants were reluctant to provide additional information. Additionally, as the results of this study are qualitative, they may not be generalized to other countries.