Tobacco in post-conflict settings: the case of

Zainab Hussain1 and Richard Sullivan2

1King’s Centre for Global Health, Conflict and Health Research Group, King’s College London, London SE5 9RJ, UK 2King’s College London, Conflict and Health Research Group, King’s College London, London SE1 9RT, UK

Correspondence to: Zainab Hussain. E-mail: [email protected]

Abstract

Tobacco is the leading cause of preventable death in the world, claiming six million lives each year. Although smoking prevalence is decreasing in high-income countries, many low- and middle-income countries, particularly fragile and post-conflict nations such as Iraq, are still seeing prevalence rates rising. With the evidence of higher rates of nicotine dependence in conflict and post-conflict areas, the tobacco problem only becomes more difficult for Iraq, which finds itself involved in conflicts lasting years, if not decades. Terrorism and unstable governments, as well as Big Tobacco, create large roadblocks on the route to adequate tobacco control. However, some tobacco control efforts have been successful in other post-conflict settings, demonstrating that with good governance, many of these roadblocks can be overcome. This review explores the context of tobacco control strategies in Iraq, identifies problems/issues, and discusses possible resolu- tions using some examples from other post-conflict countries.

Keywords: tobacco, conflict, policy, health, war, cigarette, smoking Review

Published: 28/04/2017 Received: 22/05/2016 ecancer 2017, 11:735 https://doi.org/10.3332/ecancer.2017.735

Copyright: © the authors; licensee ecancermedicalscience. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

1 with indigenous Iraqis suggest that this is no longer the case), with at least two factories in alone. Their website advertises their advertises website alone. Their Baghdad in factories two least at with case), the longer no is this that suggest Iraqis indigenous with interviews recent (although market Iraqi the of share officialTobacco State war,highest country’s 2003 the the the had to Company Prior year. Cigaretteimportshaveincreasedsincethestartofrecentconflict,with a50%increasebetween2003and2005 many mensmokethanwomen popular.rates; morethansixtimesas is reflectedintheprevalence to smoke, which for women acceptable Furthermore, itisnotculturally Iraqis are mainly exposed to tobacco through cigarettes and shisha (water pipe tobacco). Pipes, cigars, and smokeless tobacco are not as to maximiseprofits[14]. always present, including the breakdown of laws and government, and tobacco companies’ abuse of poor post-conflict governance are in causes order important However,other factors. other among trauma, and levels stress increased to attributed is This post-conflict. and ing dur- uptake tobacco in increase an is there that shows Evidence rate of10.4%[13]. very high,estimatedaprevalence use isconsidered Northern Iraq put smoking overall prevalence at 15.3%, 25.1% in men and 2.7% in women. In contrast, a similar Greek study where tobacco females, respectively and for males 4% be 31%and In Iraq, a country that has seen several wars and conflicts over the last 30 years (Table), 1 smoking prevalenceestimatesareestimatedto those withcombatexposure and especially further inthosewhoaredeployed, ofsmokinginarmyrecruits[10],whichincreases prevalence is agreaterthanaverage cigarettes smuggling situation inconflictzonestotheiradvantage, by political theweakened using of tobacco[3],companies and alsotointernational to, aremuchmorelikelytouse,and/orbe exposed tobacco. these populations stress relief This canbeattributedinparttotheperceived conflict between links towards points Evidence [2]. considered to be in active conflict or in the post-conflict setting Approximately 1.1 billion people smoke worldwide, almost 80% of whom reside in low- and middle-income countries. With 26 countries now Background The searchstrategyforthisreviewisshownin Methods Figure 1.Methods. . Increases in smoking prevalence are not limited to the civilian population; there population; civilian the to limited not are prevalence smoking in Increases [8] andshapingtobaccopolicy[9]. [11]. [15]. Tobacco is both imported and exported from the country, with Iraq producing 4.4 billion cigarettes every Interviews: NativesandvisitorstoIraqfrom 2013to2015. Language Email correspondenc Literature sear Sear Databases searc ‘prevalence’, ‘tobaccocontrol’,‘policy’,‘cigarettes’,‘smokingban’ Search term tobacco useor Eligible w Non-academic sources ebsites, Tobacco ch strateg s: Figure 1. EnglishandArabic ch studie and Post-traumatic Stress Disorder (PTSD) Disorder Stress Post-traumatic and [3, 4,5] : [12]. Global The Youth TobaccoKurdistan, in conducted olds) 15-year to (13- Survey s y: : ‘smoking’,‘Iraq’, e: Identifying sourcesofinformation ontobacco s co CentralStatisticalOrgani : Containingdataorinformationabouthealthand/or ntrol he companywebsites,medi d use/control inIraq : PubMed,MEDLINE , some 1.5 billion people are living in high exposure risk settingsworldwide exposure in high are living people [1], some1.5billion in Iraq : Google,IraqiMOH,UNand 2

‘w ar’, ‘conflicttobacco’,‘s sa a outlets,ASH. tion, Iraq. WH O mu ggling’, [6, 7]totobaccouse;asaresult, ecancer www.ecancer.org [16]. 2017,11 :735

Review . In a 2008 study of students in Baghdad, 67.9% had seen pro-cigarette advertising on billboards, 67.6% had seen had 67.6% billboards, on advertising pro-cigarette seen had 67.9% Baghdad, in students of study 2008 a In out thecountry[24]. through- up are cigarettes advertising billboards places, public in smoking and advertising tobacco ban that place in legislation Despite claiming thattheirproductcontainslessharmfulcarcinogens comparedtoimportedcigarettes) company,tobacco state Iraq’s for website the on seen as or tar’, ‘low as such terms using by (i.e., others than ‘healthier’ as product their advertising with away get can companies tobacco so advertising, misleading on laws no also are There them). on warnings have do Iraq are warnings Health in sold packs all is good; this area in compliance (although for violations place no finesin cigarette packets,butthereare on mandatory information. such acquiring in difficulty to due presumably rated, not are document the within listed strategies tion preven- the of Many advertising. outdoor and billboard on bans environments, smoke-free with compliance low/no is there but print, and strategies prevention tobacco to compliance for scores varied has Iraq However, if smoking cessation strategies are integrated into existing systems, they will gradually improve as the health system is strengthened. prevention into existing primary healthcare services. This can be seen as problematic, seeing as primary health care in Iraq is not up to standard. funding. The easiest way to implement smoking cessation support in a country such as Iraq, as recommended by WHO, is to integrate tobacco or nicotinereplacementtherapy(notcostcovered). Tobacco controlprogrammesarenotseenasapriorityduetoscarcerecourses andlackof but is seen across the Eastern Mediterranean region. Thirteen per cent of the region has no cessation services, and 48% have minimal services made availableonlyrecently,Iraq to limited problem a not is butvareniclineisnotlegallyavailable,eitherprivatelyoronprescription[22] . This health clinics, or anywhere else in the community. Nicotine replacement therapy is available to buy from local pharmacies. Bupropion has been TobaccoGlobal Epidemic the on report 2011WHO the to According had littletraction. Despite national legislation to enforce the FCTC, to date smoking cessation programmes and broader tobacco prevention measures have who signedtheframeworkon29March2004 The WHO Framework Convention on Tobacco Control has 188 signatories, out of the 193 United Nations member states, including Iraq Iraq anditsfailuretoenforcetheFCTC hydrizin materialwhichcausecancerdiseasewhilethepercentageinourcigarettesfromthisiswithinacceptablelimit’ from ‘most oftheimportedcigarettescontainhighpercentage cigarettes; imported to compared ‘safer’ and Iraqi 100% being as product • • • • • •

ing thegeneralpublicthroughschoolsandhealthorganizations’ [20] to bebuiltwithinworkplaces); banning banning thesaleoftobaccoproductstoandbyminors; requiring writtenandpictorialhealthwarningsonallpackagingoftobaccoproducts ‘banning allformsoftobaccoadvertising,promotionandsponsorship Raising providing incentivestotobaccogrowersswitchalternativecrops; public awareness of the impacts of tobacco on health, the environment and the economy,and the environment on health, of theimpactstobacco awareness public target- programmes byintroducing smoking in public places, including theatres, hotels, restaurants and shopping malls (but allowing designated smoking areas smoking designated malls (butallowing theatres, hotels,restaurantsandshopping places, including in public smoking Table 1.ListofmostrecentconflictsinvolvingIraq. 2014-date 2003–2011 1998 1995–1996 1991 1990–1991 1980–1988 Year [19]. InMarch2012,Iraqputthroughnewlegislationontobaccocontrol,whichincluded: , smoking cessation support is non-existent in Iraq; in hospitals and and hospitals in Iraq; in non-existent is support cessation smoking [21], 3

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Review Figure 2.ChangesincigarettepricesIraqfrom1990to2012 a decreaseinsmokersnowwouldarguablyreducethecostofhealthcarespendingfuture. further,revenue of smokers. the numbers reduce helping also while spending, health of public source is themajor revenue As government However,place. in mechanisms control tive toputreal to betaxedappropriately,were ifcigarettes government increase initially theywould and, with prevalence rates so high and so little competition, it can be assumed that the Iraqi government does not have much of an incen- for Company Tobacco(State SCTC the and duty import via cigarettes, of imports and sales from Cigarettes) revenue and gain does state Iraqi the that fact the ignore to difficult is It practice. into them put to failed has but this for place in policies has Iraq advertising; outdoor and places public in smoking on ban the include this of paper.Examples on exist only initiatives prevention tobacco many that is reality the TobaccoControl, on Convention Framework its of some with complying for ratings high and average Iraq give does WHO Although factors stackedagainstsuchpublichealthmeasures? complex. The question is whether tobacco control is realistic in such settings given the multiplicity of political, security, social and economic more far country,is income economies [26]. inemerging Iraq settings, withsomerareexamples middle for post-conflict situation a the As Tobaccobans etal such astaxation,advertising controlinterventions do work, but the evidence is almost entirely drawn from high-income Obstacles tosuccessfultobaccocontrol to buy100packsofthemostpopularbrandisjust0.66% required GDP of percentage The available. brands cheaper are there that considering especially affordable, extremely is cigarettes 20 of 140% from 2002 to 2012 only translates to a 0.53 USD increase in price. With Iraqi GDP at 5790.5 USD per capita pre- and post-2003. However, cigarette prices in Iraq are among the lowest in the world; even with increases in taxation, a price increase of 2015 in USD 0.78 just 20 of pack a of cost average the making cigarettes, 2014 of as 19.24% duty; import small a only with minimal is Iraq in cigarettes on taxation present, At middle-income countries and low- in 8% to up goes percentage This countries. high-income in decrease 4% a to leads 10% by cigarettes of price the Increasing countries middle-income and low- in rarer is quitting although tobacco, use to starting people fewer and tobacco quitting people of taxation tobeaneffectiveresource settingshasproven all numbers to greater lead increases price prevalence; smoking waytodecrease According to WHO and others, tax increases are ‘the single most effective intervention to reduce demand for tobacco’ Although thereare‘nosmoking’ signsupinhospitalsandotherpublicbuildings,thesearerarelyenforced. advertis- discounts, etc.)[22]. promotional etc.), (freedistribution, billboards, andascoreoffourforindirectadvertising ing (television,magazines, tobacco direct on measures control for compliance, top is 10 where 10, of out four of score average an Iraq magazines’ gave or WHO 2015, newspapers in advertising pro-cigarette seen had 59.8% and locations, sale of point at advertising pro-cigarette [27].

Price (USD) 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0 9519 9520 052010 2005 2000 1995 1990 1985 [22]. [31]. Ci ga ree 4

Year Price s [28]. Prices havediffered overtheyears(Figure2), especially 2015 . No other taxes are levied on [22]. Noothertaxesarelevied ecancer [29], 78 centsfor a pack [26]. Evidence from www.ecancer.org 2017,11 . In [25]. :735 [26].

Review Figure 3.Stepsoftheschemeto smugglecigarettesintoIraq(inplacesinceatleast August 1999)[35]. acrossgovernment andothersectors. trol andtherewasgoodcollaboration The saleandimportoftobaccoproductsbyforeign Iraq with war eight-year their after just 1990s, the in advertising tobacco on ban complete a implementing in successful been had which Iran, neighbouring is example such One Iran fully implementedtobaccocontrolpolicies. success- have countries post-conflict Other cause. lost a means no by is Iraq in control tobacco brings, conflict that obstacles the Despite Beyond Iraq:post-conflicttobaccocontrolacrosstheworld driving smugglingisthecompetitionbetweentobaccocompaniestoincreasemarketshare[35]. Union European the and Morris Phillip between to in transit. Many of these shipments were destined for Iraq’ cigarettes havebeensentbyRJReynoldsTobacco CompanytoCyprus. Approximately halfoftheseshipmentswereexportedfromCyprus would beremovedfromproductstopreventthembeingtraced(Figure3). The reportnotedthat,‘Since1996,approximately50billion marks/numbers and containers different in packed be would they routes; transport complex through Iraq to way their find would Cigarettes 1990s. the as early as Iraq to products their distributing illegally been the had that companies demonstrated tobacco Union American pean Euro- the by uncovered evidence The how pervasivetheissuehadbecomewithdirectcomplicitybymajortobaccocompanies[32,33]. just showing Iraq, into products tobacco their smuggling in part their for Morris, Philip and Reynolds RJ companies, tobacco two American Illicit cigarette trade is a known problem in Iraq, but how deep does this issue go? In 2002, a law suit was filed by the European Union against gling ofcigarettescomparedtothesmugglingillegalsubstancesbyensuringallaresourcedvialegitimatechannels.[31] when itcomestosmuggling.However, withthecooperationofgovernmentsandtobaccocompanies,itcanbemucheasiertocontrolsmug- of 10 million cigarettes can bring in a profit of 1.9 million USD), and decreased risk due to its legal status, cigarettes are preferable to narcotics the PKK (Kurdistan Worker’s Party), to the IRA and CNDP (National Congress for the Defence of the People). With high profits (one container and over,al-Qaeda world from the conflict in used been has smuggling Cigarette groups’. rebel of activities the and corruption of levels high UK, smuggling in conflict settings is not influenced by differing taxation levels in surrounding countries, but the ‘outcome of weak state capacity, free, andcigarettesmugglingbeingusedtofinancerebelgroups. They drawattentiontothefactthat,unlikesmugglingincountriessuchas factors thathelpescalatetheproblem;difficulty ofmonitoringbordersinconflictsettings,corruptgovernmentsthatallowsmugglerstoreign Another roadblock to overcome is tobacco smuggling, which is endemic to post-conflict environments . What made this task slightly easier for Iran is that their tobacco industry was under state con- state under was industry tobacco their that is Iran for easier slightly task this made What [36]. were second vesselusingtheSpanishportfacilities.From Valencia, Spainbycar shipped containersofW final destination. were cigarettes werereloadedintonewcontainers,bearingdifferent 3. InCyprus,the 2. InSpain,the 1. JapanTobacco, Habur bordercrossingandintoIraq. 6. Tho with 5. Thefiveforty-footcontai 4. Subsequently,t 5,340maste exportedfromC shipped toCyprus. se fivecontainerswerethenshippedoverlandthroughTurkeytothe . What is clear is that in post-conflict Iraq, with its low tax burden on cigarettes, what is is what cigarettes, on burden tax low its with Iraq, post-conflict in that is clear is What [34]. co r cases)we co he ntainers we lo ntainers wereunpac conta ca yprus, go shi ted inPuertoRicoandactingunderlicenseofRJR, in

ston brandcigarettesfrom ners in with “Russia p. ers containingtheW re re s off wi hi th pp -loaded andlaterre [32]. The law suit was dropped in 2004, after an agreement was reached theW

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ke ” fals d andtheWinston in ston brandcigarettes(packed ely declaredasthecountryof inston brandcigarettes theUnitedStatesto Spain,thecontainers -loaded ontoa brand ma rkings rk ey. ey.

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Review measures thathavebeensuccessfulpreviouslycanalsobe implementedinIraq. control tobacco that evidence some least at is there initiative, smoke-free Vietnam’s and ban, advertising successful their with Iran ples: to othercountriesasexam- tobacco companies.Looking of international government andtheinvolvement even moresobyitsweakened There is no denying that tackling tobacco has been and will continue to be extremely challenging for Iraq in the post-conflict setting, made Conclusions workplaces arevirtuallyallsmoke-free. closely with a myriad of organisation, managing to achieve high levels of compliance of the smoke-free regulations; schools, hospitals, and tising bans and health warnings on cigarette packets but performed poorly in enforcing their smoke-free laws. After 2007, the MoH worked and Initiative technical support Bloomberg of WHO, the the Campaign for Tobaccoof support Free Kids (TFK), financial and others. Prior government, to this, Vietnam new had strong enforcement of a adver- of introduction the with 2007, in intensified efforts Tobaccocontrol on Tobacco Control(althoughtheirtobaccocontrolefforts startedin1989withtheintroductionofanadvertisingban) Vietnam30 Convention Warthe on Framework later,conflict, ended WHO years of finally1975. the Thirty Vietnam April adopted 2005, in Vietnam has higher than average prevalence rates; about a quarter of the adult population smoke, mostly males Vietnam changes toitstaxationstructure,shiftingtherecommendedsingle-tieredsystem,whileadjustingtaxratesyearly, withinflation. decreasing cigarettesalesoverall.Pakistan,nowonthewaytobettertobaccocontrol,willneedcontinueintheirefforts andmakefurther in pricebetweenthemoreexpensiveandcheaperbrandswillleadtomanysmokersswitchingbrandof cigarettes, insteadof more expensive cigarettes have greater excise duty rette taxation[41]. In 2013, Pakistan restructured their tobacco taxation, changing from a multi-tier to a more simplified two-tier system, where of fatalities a year. Between 2009 and 2010, with the technical assistance of WHO and Bloomberg Initiative funding, Pakistan increased ciga- Pakistan has a long history of conflict, starting with the first Indo–Pakistan war in 1947. Presently, the ongoing insurgency is causing thousands Pakistan media, whichwasnotasignificantissueatthetimelawcametopass. by tobaccocompaniesandmedia. There wasnowacompletebanonalldirectandindirecttobaccoadvertisinginexceptelectronic exploited previously that were many oftheloopholes addressed and legislation to previous compared act wasvastlymoredetailed The new for violationsweresmall.Naturally, tobaccofirmstookadvantageofthisandcontinuedtheiradvertisingcampaigns. of tobaccoproducts.However,a banondirectadvertising included and fines it failedtoaddressindirectadvertising,waspoorlymanaged through passed later was Act Restriction that Use Tobaccothe law Product as new parliament a drafted Health of Ministry Croatian the Independence, of War the of end the after years Four Croatia stable [38],with20%ofmalesand2–3%femalessmokingdaily fairly remained has prevalence and place in measures control tobacco good has still Iran although thesehavenot been significant[38]. since, rates prevalence in increase some seen has Iran bans. advertising the opposing started companies Predictably,these privatised. 1999 and 1991 transnational brands between finding their way rates into the country smoking via smuggling in routes, Iran finally decline submitted to pressure a and the tobacco in industry was resulted taxes, tobacco in increases and gramme tothebanbyBig companies werenotpermitted,andsotherewasnorealopposition Tobacco. This, alongwithahealtheducationpro- [42]. Although this will go some way to decrease tobacco use, the increased difference . Prior to this, Croatia had weak legislation governing tobacco control,which [40]. governing Prior tothis,Croatiahadweaklegislation [39]. 6

[37]. However, mostlydueto [43]. After almost 20years ecancer [44]. www.ecancer.org 2017,11 :735

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