1. Background
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.
2. Objectives
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.
3. Methods
3.1. Study Design
This qualitative phenomenological study was conducted using content analysis in the first half of 2023.
3.2. Population and Research Sample
The study population included policymakers, legislators, members of parliament, experts (both academic and executive), and researchers involved in the tobacco control process in the country. A purposefully heterogeneous sample of 21 individuals was selected. To ensure diversity and comprehensiveness in participant selection, various criteria were considered, including the individual’s involvement in policymaking, area of expertise, extent of experience, perspective on the topic, and affiliation with relevant organizations (Table 1).
Table 1.Demographic Information of Research Participants
| Participants | Gender | Age (y) | Occupation | Work Experience (y) |
|---|---|---|---|---|
| 1 | Male | 55 | Secretary General of the Population Against Smoking | 28 |
| 2 | Male | 36 | Head of the Tobacco Control Research Center | 11 |
| 3 | Male | 44 | NGOs, Ministry | 22 |
| 4 | Male | 53 | Tobacco Control Coalition, Legislative Drafting | 23 |
| 5 | Male | 30 | Head of the Tobacco Control Secretariat in the Ministry of Health | 4 |
| 6 | Female | 53 | Responsible for Population-Based Anti-Tobacco Research | 26 |
| 7 | Male | 32 | Ministry, Convention Association | 10 |
| 8 | Female | 48 | Retired member of the Tobacco Committee | 26 |
| 9 | Male | 35 | Health Department, Tehran Municipality | 4 |
| 10 | Female | 45 | Customs | 15 |
| 11 | Male | 37 | Tax Affairs | 9 |
| 12 | Male | 33 | Head of the Broadcasting Organization | 5 |
| 13 | Male | 37 | Ministry of Education | 12 |
| 14 | Male | 43 | Smuggling Prevention Headquarters | 14 |
| 15 | Male | 45 | Ministry of Foreign Affairs (Convention) | 12 |
| 16 | Female | 34 | Ministry of Industry and Mines (National Tobacco Control Center) | 9 |
| 17 | Male | 47 | Islamic Culture and Guidance | 14 |
| 18 | Male | 35 | Department of Justice | 5 |
| 19 | Male | 39 | Ministry of Agriculture | 12 |
| 20 | Female | 43 | Health Assistants in Universities | 14 |
| 21 | Male | 37 | Police | 6 |
Inclusion criteria: Participants had direct experience with tobacco control policies, possessed a relevant professional background, had been involved in tobacco control initiatives for at least four years, and were willing and able to participate in the study.
Exclusion criteria: Individuals with four years of work experience who had taken more than six months of sick leave, as well as those with a conflict of interest, were excluded from the study.
3.3. Research Tools and Data Collection Methods
Data were collected through semi-structured interviews guided by an interview protocol. The interview guide was developed based on a literature review and was piloted before the study commenced. The research team confirmed its validity. Prior to the interviews, the interview guide was presented to the participants in person. Interviews were conducted in person according to participants' preferences and prior arrangements. All sessions were recorded, and notes were taken.
Initially, participants were asked to provide demographic information, including age, job position, and work experience. The discussion then shifted to an open-ended question:
"What is the status of tobacco control in the country? What are the challenges in tobacco control? How can tobacco consumption be controlled in the country?"
This question initiated a discussion on participants’ views and the challenges of tobacco control policymaking and legislation. Each interview lasted between 40 and 60 minutes, and a unique code was assigned to each interview to maintain the confidentiality of participants’ responses.
3.4. Data Analysis
Data collection and analysis were carried out simultaneously until data saturation was reached, based on the method suggested by Graneheim and Lundman. This method involves the following steps: (1) Conducting interviews and thoroughly reviewing them to ensure a comprehensive understanding; (2) extracting semantic units or key themes and categorizing them into concise units; (3) summarizing and organizing these units under appropriate headings and selecting suitable labels for them; (4) arranging sub-categories and (5) selecting an appropriate title that encompasses the identified categories (22).
In this study, within 24 hours of each interview, the recorded data were listened to three times and transcribed verbatim onto paper before being typed. The analysis process began concurrently with the initial interview. During the analysis, the transcripts were meticulously reviewed line by line to identify the units of analysis, treating each interview text as a single unit. A semantic unit focusing on challenges related to tobacco control policy and legislative processes, along with practical solutions, was determined. For the first two interviews, two study members, AM and NM, agreed on the important paragraphs and meaning units related to the main challenges and operational strategies associated with the development of tobacco control and started coding.
Coding was performed using MAXQDA software version 2020. After coding, NM, SG, and AM compared the codes to assess their conceptual similarities and differences. Codes that shared similar concepts were grouped into more refined and abstract categories. Continuous comparison of these categories facilitated the identification of underlying themes within the data, organized under a central main theme. Any disagreements were discussed and resolved by two researchers. Finally, all themes were refined and agreed upon by all researchers at the end of the analysis. To enhance the accuracy and precision of the study, Guba and Lincoln’s criteria, including credibility, dependability, confirmability, and transferability, were applied (23).
3.5. Ethical Considerations
In this study, ethical considerations were ensured through the following measures: (1) The study was approved by the University Research Ethics Committee; (2) all participants signed an informed consent form before the interview; (3) participation in the study was entirely voluntary; (4) to maintain confidentiality, each interviewee was assigned a unique code, ensuring the anonymity of their information.
4. Results
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.
Table 2.Challenges Related to the Process of Tobacco Control Policy Making and Legislation
| Main Topics | Subtopics |
|---|---|
| Policy development and legislation related to tobacco control | Failure to update laws in accordance with international convention |
| High frequency of meetings involving the Deputy Minister of Health, the Minister of Health and the Secretariat | |
| Conflicts of interest in tobacco control policy | |
| Barriers to the involvement of tobacco industry agents in tobacco legislation | |
| Improper position the Secretariat of the National Tobacco Control Headquarters | |
| The multidisciplinary nature of tobacco control | |
| Normalization of tobacco related offenses | |
| Poor media literacy about tobacco issues | |
| Insufficient attention to tobacco related issues at the Ministry of Health level | |
| Insufficient knowledge of international tobacco control processes among some representatives of the Islamic Council | |
| Interventions and inconsistencies among governmental bodies and other institutions in relation to the Ministry of Health | |
| Presence of tobacco industry agents trying to influence stakeholders | |
| Lack of prioritization of tobacco issues in national health programs | |
| Neglecting tobacco-related priorities in the country's health initiatives | |
| Weakness in research efforts in Iran | |
| Ignoring scientific findings from domestic studies | |
| Being justified or not by the legislator in the parliament | |
| Insufficient recognition of health risks associated with tobacco stakeholders | |
| Lack of qualified personnel within the Secretariat of the National Tobacco Control Headquarters | |
| Lobbying efforts by tobacco companies | |
| Composition of the National Tobacco Control Headquarters | |
| Inability of the Ministry of Health to raise tobacco taxes | |
| Conflicts of interest between the Ministry of Industry and the Ministry of Health | |
| Altering the pattern of tobacco consumption | Rising incidence of smoking among women and individuals under 18 years of age |
| Concerns regarding high consumption of hookah | |
| Prevalence of smoking and hookah use in traditional restaurants and cafes | |
| Introduction of new advertisements regarding the use of flavored tobacco products | |
| Unfavorable economic situation in the country | |
| Depiction of smoking in films and media productions | |
| Enforcement of laws and regulations | Insufficient law enforcement |
| Inadequate inter-departmental coordination | |
| Non-enforcement of regulations prohibiting single cigarette sales, sales to individuals under 18, and restrictions on guilds selling cigarettes | |
| Lack of coordination among involved organizations | |
| Insufficient follow-up on the enforcement of related laws by the secretariat | |
| Challenges in implementing the approvals of the National Tobacco Control Headquarters | |
| Inadequate supervision by the Ministry of Culture and Islamic Guidance on home network series and films | |
| Limited executive commitment in other organizations | |
| Challenge associated with simplified packaging of tobacco products | |
| Migration of the tobacco industry to developing countries | |
| Organized trafficking activities | |
| Infrequent meetings | |
| Weakness in the punitive framework | |
| Inability to prevent criminal activities | |
| Low taxation on tobacco products | |
| Provision of subsidies to tobacco companies through importing cigarette paper with government currency |
Table 3.Operational Strategies to Solve the Challenges Associated with the Policy Making and Legislative Processes of Tobacco Control
| Main Topics | Subtopics |
|---|---|
| Policy development | Establishing a regulatory body for tobacco control |
| Promoting cultivation at the level of medical sciences universities | |
| Emphasizing the need for national commitment to control tobacco | |
| Prioritizing tobacco control initiatives | |
| Using the capacity of two representatives from the parliament commission in the national headquarters of tobacco control | |
| Supporting domestic tobacco production | |
| Investing in alternative consumer markets | |
| Capacity building of the staff of the National Tobacco Control Headquarters in the Ministry of Health | |
| Supporting scientific centers and non-governmental organizations engaged in tobacco control efforts | |
| Comprehensive monitoring and continued efforts by the anti-tobacco advocates in parliament and the Health Commission to raise awareness among other representatives about the significance of addressing tobacco-related issues | |
| Ensuring the presence of specialized personnel within the Secretariat of the National Tobacco Control Headquarters | |
| Aligning national regulations with international laws | |
| Improving the operational effectiveness of the Secretariat of the National Tobacco Control Headquarters | |
| Adopting international best practices in tobacco control strategies | |
| Enforcement of laws and regulations | The capacity of the primary health network to control smoking |
| Using primary health network human resources and experiences |
4.1. Challenges Associated with the Development of Tobacco Control Policies and Legislation
4.1.1. Policy Development and Legislation Related to Tobacco Control
Developing policies and laws to regulate tobacco can significantly improve public health in Iran; however, several challenges persist in this area. These obstacles include the failure to update laws in line with international conventions, the involvement of multiple organizations in tobacco policy-making, and insufficient knowledge among Iranian Parliament representatives about international tobacco control processes.
Additional challenges include lobbying by tobacco companies, the improper positioning of the National Tobacco Control Headquarters Secretariat, conflicts of interest in tobacco control policy-making, weaknesses in tobacco research in Iran, and inadequate media advocacy.
Participants of the study stated: "Our domestic policies are influenced by international laws, especially in areas concerning taxes and tobacco products. When international laws evolve in a progressive manner, it is crucial for us to update our domestic laws accordingly. We may do this because of the concern about employment. The current laws may also be weakened. It's time to adjust them with the current standards" (participant 1).
"Tobacco control is a multidisciplinary phenomenon, and different systems are involved in it, which means that one organization alone cannot be the enforcer of the tobacco control law. For example, in the comprehensive tobacco control law, illegal or smuggled tobacco products are mentioned. Well, the Ministry of Health is administratively at the same level as other ministers and has no involvement at all in controlling entry and exit points for smuggling" (participant 2).
"The broadcasting organization, especially television, has less cooperation; radio has more cooperation. They do not allocate effective daily hours to tobacco control. If there is a program related to tobacco, it is broadcast during the tobacco week in the country's calendar and during low-viewer hours" (participant 9).
"In the field of taxation, the Ministry of Health and the Ministry of Economy also make suggestions, but the conflict of interests and the lobbying of tobacco companies cause the approved tax to be lower than the proposed amount" (participant 15).
"Most of the emulations are based on international experiences, so less attention is paid to the scientific experiences derived from domestic studies" (participant 10).
4.1.2. Altering the Pattern of Tobacco Consumption
The tobacco control policy in Iran faces significant challenges due to the increasing prevalence of various types of contraband tobacco production and diverse methods of consumption. The patterns of tobacco use are changing across different age and gender groups, with a growing trend of smoking and hookah consumption in traditional households and cafes. Additionally, the promotion of tobacco use in films and media, along with new advertising strategies featuring perfumes and flavors, further complicates the issue. Economic factors and individuals’ employment status also play a crucial role in tobacco consumption.
"TV and home network series have some indirect advertising that the Ministry of Health usually reacts quickly to, or in movies that show the heroes of the story smoking. In fact, there is little supervision by the Ministry of Culture and Islamic Guidance, and smoking is portrayed as an easy activity" (participant 3).
"These taste and aroma substances attract people to increase nicotine consumption. It increases nicotine addiction. It is one of the strategies of the tobacco industry to lure young people into smoking with aromatic tobacco" (participant 1).
"Tobacco consumption among women has now increased with the promotion of slim and colorful cigarettes, which are attractive to young people, especially women. Their strategy is to maintain themselves in any way and attract new age and gender groups to the consumer market every day" (participant 14).
"In the southern regions, hookah consumption is high. Our challenges are very significant; we have many land and water borders, and there is organized smuggling and mafia" (participant 8).
4.1.3. Enforcement of Laws and Regulations
Effective implementation of tobacco control laws and regulations in Iran requires strong legislation, robust enforcement, and effective inter-sectoral coordination. However, several challenges hinder these efforts, including inadequate law enforcement, lack of coordination between sectors, and failure to enforce laws prohibiting tobacco sales to minors and the sale of cigarettes in unauthorized shops.
Other contributing factors include organized smuggling, irregular meetings, weak punitive measures, lack of deterrence for tobacco-related offenses, and low tobacco taxes. Additionally, subsidies provided to tobacco companies through imported cigarette paper purchased with government currency, insufficient follow-up on the implementation of relevant laws by the Secretariat, difficulties in executing decisions made by the National Tobacco Control Headquarters, and inadequate supervision by the Ministry of Culture and Islamic Guidance over domestic TV series and movies further complicate the situation.
"The main weakness is the lack of a strong authority to enforce laws. Despite the Ministry of Health playing a primary role in this regard, it lacks fundamental tools in many areas. For instance, the tax on tobacco products is approved as part of annual budget programs in the open floor of the parliament, and the Ministry of Health presents good proposals in this regard. However, what often happens in the open floor of the parliament is generally lower than the Ministry of Health’s proposal" (participant 5).
"According to the law, several trades have the right to sell cigarettes, and trades such as newsstands, juice shops, or bakeries do not have the right. But unfortunately, in Iran, cigarettes are also sold in these places" (participant 11).
"In terms of the packaging of tobacco products, they should also have simple packaging. But tobacco companies did not comply. They attract consumers with attractive packaging" (participant 3).
"The level of encouragement for local manufacturing lowers the prices of domestically produced cigarettes, making the domestic brands more affordable, while the tax on imported goods rises, leading to an increase in their prices. However, this approach does not impact the reduction of consumption" (participant 13).
"One of the weaknesses of our law is that the penalties are updated every three years based on inflation coefficients, but they are not sufficient to be deterrent. The consumption of tobacco in public places is the same; for example, the penalty for advertising has reached 440 million Iranian Rials for the third offense, selling to under 18 is about 80 million Iranian Rials, and selling without a license is 280 million Iranian Rials. These amounts are not deterrent at all for an industry that makes a lot of profit. The penalty that an individual pays for not enforcing the law is very low. People smoke in public places but are not penalized. We do not have the structure for imposing penalties" (participant 3).
"Article A102, Note 3 of the Law of the Fifth Development Plan of the Government obligated the government to convert tobacco imports into domestic production. This decision led to a large number of foreign brands investing in the country, claiming that they are creating job opportunities, providing free electricity and labor force, and recommending the government to support them financially as they play a role in the economic cycle. The government started granting foreign currency for raw materials, etc. There are many challenges to controlling tobacco, but the most important one is that tobacco industry actors should not interfere in policymaking. Whenever we got into the discussion of taxes, they intervened in this issue" (participant 6).
4.2. Operational Strategies to Address the Challenges Associated with the Policy and Legislative Process of Tobacco Control
4.2.1. Policy Development
One key operational strategy in tobacco control is ensuring efficient policy development at the national level. This can be achieved by: Engaging specialized experts within the national tobacco control authority, aligning domestic legislation with international standards, enhancing the capacities of the national tobacco control authority, learning from global best practices, fostering a culture of tobacco control within medical institutions, establishing a regulatory body dedicated to strengthening the country's commitment to tobacco regulation.
"If the head of the national headquarters becomes the President, decisions will be followed up more firmly" (participant 3).
"Promoting cultural change in 64 medical universities and establishing a tobacco-free city or village nationwide" (participant 12).
"The Ministry of Health should prioritize the issue of tobacco control. The main question is, what position does the National Tobacco Control Secretariat hold within the ministry's structure? Organizational structures need to be revised. The tobacco control department should be at the level of a large directorate under the ministry's organizational chart. Regular committee meetings should be held, utilizing the coordination capacity and the power of the ministerial level in enforcing the law" (participant 3).
"Part of our domestic laws is inspired by international laws. As soon as foreign laws evolve, we should update our domestic laws as well. We may weaken our current laws due to concerns about unemployment. It's time to adapt the law to the current standards" (participant 6).
4.2.2. Enforcement of Laws and Regulations
A critical approach to enforcing tobacco control laws and regulations is leveraging the capacity of the Primary Health Care (PHC) network within the country. With its extensive coverage and close ties to the community, this network has significant potential for educating individuals about the health risks associated with tobacco use and organizing public campaigns to support smoking cessation.
Additionally, the PHC network, through its specialized and experienced personnel, can provide services related to smoking cessation, including counseling, medications, and support groups. By focusing on prevention, cessation, and policy enforcement, the PHC can play a substantial role in tobacco control efforts, helping to reduce the burden of tobacco-related diseases within the population.
"The capacity of the primary health network should be used to control tobacco. Health inspectors can be deployed even in the most remote areas to enforce tobacco control laws through inspections" (participant 16).
5. Discussion
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.
5.1. Conclusions
Based on the findings, the challenges related to tobacco control in Iran encompass a wide range of legislative, enforcement, economic, and societal factors. The issues surrounding tobacco control in Iran are deeply interconnected and multifaceted, requiring a comprehensive, multi-disciplinary, and integrated approach to effectively address them. This approach should include not only legislative reforms but also the enforcement of existing regulations, public health initiatives, economic measures, and cross-sector collaboration. Furthermore, addressing these challenges requires a strong commitment to evidence-based policymaking, rigorous enforcement of regulations, public awareness campaigns, and targeted interventions focusing on critical issues such as youth smoking, tobacco advertising, and the economic factors influencing tobacco production and consumption.
In summary, a multifaceted strategy that integrates policy reform, public education, and community engagement will be crucial for Iran to overcome the current challenges in tobacco control and to promote healthier lifestyles among its population. The strengths of this study lie in its comprehensive analysis of existing tobacco control measures and its emphasis on innovative, evidence-based strategies, which can serve as a valuable resource for future research. Additionally, it is recommended that further studies be conducted to explore the underlying causes of tobacco use and to develop effective strategies for reducing tobacco consumption among users.
