Stamping out Tobacco Use in the Middle East and Africa

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Tomorrow’s regular customers? Stamping out tobacco use in the Middle East and Africa

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A report from the Economist Intelligence Unit Tomorrow’s regular customers? Stamping out tobacco use in the Middle East and Africa

Preface

omorrow’s regular customers? Stamping out tobacco use in the Middle East and Africa is a research Tpaper written by the Economist Intelligence Unit and sponsored by Pfizer. The author is Jason Sumner and the editor is Katherine Shields. Vanessa Barchfield also contributed to the report. The findings are based on more than 40 interviews with experts from government, academia, NGOs and the tobacco industry in the Middle East, Africa and elsewhere. We would like to thank the Economist Intelligence Unit’s extensive network of country analysts for organising and conducting most of these interviews. We would also like to thank our sponsors and the experts who participated in the interviews for their time and valuable insight. The views in this report are those of the authors, and do not necessarily represent the views of, and should not be attributed to, Pfizer.

October 2009

Introduction and key findings

n much of the Western world, smoking is in retreat. After peaking in the post-second world war Iera, tobacco consumption has been in steady decline since the 1970s, halving in many countries as the evidence around nicotine’s detrimental health effects swelled. Over the decades, incremental tax hikes, advertising bans and public awareness campaigns—among other policies—have led to a seismic shift in public attitudes towards smoking. Governments, wary of the future burden that a next generation of smokers could add to the already mounting healthcare costs associated with retiring baby boomers and obesity-related illness, have been pushing forward ever-tighter tobacco controls, and more expansive public awareness and cessation programmes. Acceptance is growing. France has earned praise for a national ban on public smoking enacted in 2007 that has been both well accepted and well enforced, countering the romantic popular notion that cigarettes are as inseparable from French life as red wine and cafes. In the US, home to many of the Big Tobacco producers and where adult smoking rates have already fallen from 37% to 20% in the last 40 years, Congress recently gave broad powers to the government to regulate tobacco products, and will force cigarette makers to disclose ingredients and place prominent warnings on packaging, among other reforms. Yet in the developing world, governments are only starting to wake up to the tobacco problem. According to the World Health Organisation (WHO), the developing world’s share of total smokers climbed from just over 40% in 1970 to 70% by 2005. By 2030, the WHO forecasts that 80% of tobacco-related deaths will be in low- to middle-income countries. For developing-world countries that aim to emerge as major economic players, the future social and financial penalties of rampant tobacco consumption could be crippling. Preventable, early deaths first and foremost cause unnecessary suffering at an individual level. At a macroeconomic level, premature mortality among those who would otherwise be healthy saps national productivity. The Centers for Disease Control (CDC) in the US reckons that lives shortened by tobacco consumption cost the country US$97bn per year. The European Union calculates yearly productivity losses in Europe at between €69.8bn and €86bn. Soon—and in many countries the impact is already being felt—governments grappling with expanding welfare costs as their populations age will have to add the burden of treating smoking-

related diseases such as cancer, heart disease and respiratory disease. Health ministers throughout the emerging world understand the risks, but progress on anti-smoking policies has been sluggish because of the addictive nature of nicotine and politicians’ understandable reluctance to turn their backs on the revenue and jobs provided by the tobacco industry. This report focuses on one portion of the developing world—the Middle East and Africa (MEA)— which has become a key battleground in the struggle over government policy and public attitudes. Although the region can lay claim to adult smoking rates mostly on par or lower than those of many Western and developing nations, expanding populations mean that even if rates were to stay relatively steady, the absolute numbers of smokers would still rise. The MEA region also poses other deeply entrenched challenges. These include rising youth smoking rates, particularly among girls, a prevailing culture of acceptance around tobacco, especially the water pipe, widespread governmental ambivalence and a strong tobacco industry lobby. But charities and other non-governmental organisations (NGOs) have gained a foothold in recent years. They often work on a shoestring, but are increasingly supported with much-needed financial lifelines from rich Western philanthropists. “There is a change in mentality in our region. Ministries of health are working with the WHO and other NGOs—bringing together all the people working on tobacco control,” says Dr Jean-Pierre Baptiste, a regional adviser with the WHO’s Tobacco Free Initiative in Algeria. He is one of more than 40 experts from government, academia, NGOs and the tobacco industry interviewed for this report. But are their efforts enough? In this paper, we investigate the progress that has been made, the challenges that remain, what lessons can be drawn from successful policies elsewhere and how the landscape could look in a decade or two. We examine ten major markets in-depth—four in North Africa: Egypt, Algeria, Morocco and Tunisia; two in Sub-Saharan Africa: Nigeria and South Africa; and four in the Middle East: Lebanon, Jordan, Saudi Arabia and the United Arab Emirates (UAE). The key findings of the report are highlighted below. Youth smoking rates look dangerously high…and are rising In most MEA countries, while smoking rates among adults appear generally to have held steady in the last ten years, youth rates are rising. In Lebanon, which has one of the worst youth smoking rates in the region, two-thirds of boys and more than one-half of girls between 13 and 15 years of age smoke some form of tobacco, at least double the rates for Lebanese men and women. Campaigners are duly worried because most lifelong smokers start before they turn the age of 18. In North Africa and the Middle East, the water pipe has become ubiquitous Seen as trendy and traditional, the water pipe has surged in popularity in the past decade, and this factor more than any other is believed to account for the rise in tobacco consumption among children. Variously known as hookah, nargile or shisha, the water pipe can deliver a hit many times more powerful than a cigarette, yet there is a widespread belief that it is less harmful than other types of tobacco. Some parents encourage their children to smoke the pipe and it is increasingly popular with young women, who smoke it in cafes in more liberal cultures and at home behind closed doors in more conservative countries.

Governments rarely speak with one voice In general, anti-tobacco policies are weak and contradictory. Even countries that are seen as leaders in the region, such as Egypt, see infighting between ministers. Finance departments point to the revenue and jobs generated by the tobacco industry, while health ministers argue that the long-term costs of caring for tobacco-related illnesses far outweigh any short-term benefits. Bans are sometimes strict on paper, but rarely in practice Smoking restrictions vary throughout MEA, but with a few exceptions the laws are poorly enforced. Advertising bans have been more successful, with a handful of countries receiving good scores from the WHO for both the completeness of their laws and strict enforcement. Regional co-ordination is poor, however. Television ads are forbidden in Jordan, but its neighbour, Lebanon, has no restrictions, so Jordanian children are treated to a bevy of cigarette ads via Lebanese satellite. NGOs punch above their weight To the extent that governments have taken action, it is often due to the influence of NGOs. Dr Judith Longstaff Mackay, a senior adviser at the World Lung Foundation, a charity, says in the past ten years there has been a “professionalisation of tobacco control” in MEA. They focus on influencing governments and public attitudes with awareness campaigns, training and assistance for doctors, and lobbying for smoke-free zones, often one city at a time. In Nigeria, campaigners cheered when, in 2008, after much pressure, the capital city of Abuja was made a smoke-free zone. Better data are needed to support awareness campaigns, acceptance and enforcement Even on the most optimistic projections, a combination of prevalence trends and population growth means that in two decades there are likely to be several million more people smoking in MEA than there are today. Whether this depressing trajectory proves true will depend on the success or failure of anti- smoking campaigners and their allies in the health ministries. Yet success in the West in pushing down prevalence rates from the high 60% range to one-third of those rates today gives campaigners hope for MEA. With many efforts just getting off the ground, public awareness is beginning to grow. To keep up the pressure, anti-tobacco groups require consistent data on smoking rates and trends, and more hard evidence on the effects of the culturally acceptable water pipe.

Youth smokers: Don’t get them started

valuating the progress of anti-smoking campaigns starts with good data. How many people Esmoke? Who smokes? How often? How do rates compare with a decade or two decades ago? In the developed world, surveys tracking this sort of information are commonplace. In MEA, comparable data that measure trends across time are frustratingly difficult to come by. Moreover, prevalence surveys are usually based on individuals reporting their own tobacco consumption, which the experts interviewed by the Economist Intelligence Unit for this paper say underestimates the reality. This factor is especially relevant among women in MEA, who often find it culturally difficult to own up to smoking. The figures that do exist, however, give campaigners reason to believe that smoking rates among adults are holding relatively steady, and may have already peaked in some countries. Yet the same studies show that the incidence of smoking among children in the region is alarmingly high and— although robust data on trends are spotty—most experts we interviewed believe the rate is rising. First the not-as-bad news—adult prevalence The average percentage of adult male smokers in the ten countries examined in this paper is 32%, according to a 2008 WHO report*, which is the most up-to-date, comprehensive source for smoking prevalence in 135 countries. Although the fact that an average of one in three men smoke some form of tobacco cannot be considered good news, this level remains below some Western countries, where anti- smoking campaigns are more firmly established. In the US, for example, one-quarter of men are smokers. In France, Germany and the UK, the rate is just over one in three. In Japan, 44% of adult men are smokers. The average prevalence rate among women in the ten countries in our sample is 5%, well below the rates for many Western countries. For example, one-third of British women smoke, as do one-quarter of French and German women. In the US, the figure is one in five. The experts we interviewed believe that the WHO numbers for women are under-reported, and they also express concern that the water pipe is becoming more popular among women. But even if the numbers were mistaken by as much as 10%, as some experts believe, they would still come in under those for Western nations. * World Health Organisation, Campaigners are by no means complacent, because even if rates stay steady population growth WHO Report on the Global means there could be millions more smokers in 20 years’ time. But the adult prevalence figures suggest Tobacco Epidemic, 2008: The that if they are successful in implementing the kinds of anti-tobacco measures that have become MPOWER package. routine in Western countries, they could make a significant further dent in the figures.

High and rising—youth prevalence The chilling wisdom contained in an oft-cited passage from a 30-year-old Philip Morris internal document still holds true today: “Today’s teenager is tomorrow’s regular customer, and the overwhelming majority of smokers first begin to smoke while still in their teens.” Official data and anecdotal evidence suggest that if youth trends in MEA remain unchecked, tobacco companies can count on a steady flow of regular customers in the coming decades. “Young people want to be like Europeans,” says Dr Wided Hizem Ben Ayoub, an epidemiologist and smoking cessation specialist at the Salah Azaiez Cancer Institute in Tunisia. “They see smoking as a sign of independence, especially young women. So we have to do a lot of work among young people.” According to the WHO, the average prevalence rate is 26% for boys between the ages of 13 and 15 years in the nine countries in our sample (there are no comparable figures for Algeria). The figure is 18% for girls (excluding Algeria and Saudi Arabia). In Lebanon, the problem is particularly acute, with 65.8% of boys smoking, double the rate among Lebanese men; and 54% of girls, which is nine times the rate for women. By contrast, the smoking rate among 11-15-year-olds in England (excluding Scotland, Wales and Northern Ireland) is 6%, according to John Tilley of the tobacco policy team in the UK Department of Health, citing a 2008 National Health Service study. The WHO report only records smoking rates for those between 13 and 15 years, but the experts we interviewed say that the problem starts much earlier in most countries. In Algeria, for example, the WHO declined to publish a figure for youth prevalence, citing a lack of comparable survey data. Yet Dr Mokhtar Hamdi-Cherif, professor of epidemiology and preventative medicine at the University of Setif in Algeria and prominent anti-smoking campaigner, cites a 2007 survey that suggested that one-half of

Adult and youth smoking prevalence in selected countries (%) Men Boys (13-15) Women Girls (13-15) 70 70

60 60

50 50

40 40

30 30

20 20

10 10

0 0 Algeria Egypt Jordan Lebanon Morocco Nigeria Saudi Arabia South Africa Tunisia United Arab Emirates Note. Data in this chart include the WHO's age-standardised estimates to a 95% confidence interval, for the purposes of comparison across countries. Men and women are defined as adults over the age of 15 years old. Youth smoking rates are for children between the ages of 13 years old and 15 years old. The above chart identifies the adult prevalence rate for "current smoking" which is defined by the WHO as "smoking at the time of the survey, including daily and non- daily smoking." The rates reflect "smoking any form of tobacco including cigarettes, cigars, pipes, bidis, etc." Youth figures include those who "consumed any smokeless or smoked tobacco product at least once during the last 30 days prior to the survey". Source: WHO Report on the Global Tobacco Epidemic, 2008: The MPOWER package, World Health Organisation.

Algerian boys between the ages of 10 and 17 smoke regularly. In Tunisia, Dr Ayoub says some children start smoking as early as 9 years of age. In the UAE, Dr Wedad Al-Maidoor, director of PHC Dubai health centres and the head of the Centre’s tobacco control team, says smoking among 12- to 16-year-olds is between 25% and 30%, considerably higher than the WHO estimate of 13.2% for boys between 13 and 15 years. She says there is a false belief that smoking is traditional. “There is no part of our heritage that says we are happy with smoking. It wasn’t inherited from the history of this country. We imported it from other cultures and countries, and it has now come to be socially acceptable.” Smoke in the water Throughout the Middle East and North Africa, experts point to one common denominator that explains why tobacco use is rising among children and young women—the widespread acceptance and popularity of the water pipe. Known as shisha, nargile or rengila, the water pipe is seen as less harmful, even though one session with the pipe can deliver many times the impact of a single cigarette, according to some experts. “It is a social activity in the evening or at the weekend,” says Dr Hani Algouhmani, the Eastern Mediterranean regional director for the Framework Convention on Tobacco Control, a treaty binding signatories to a number of anti-tobacco measures. “It’s traditional, but it is also fashionable. If you

Convincing adolescents: Combating youth smoking In order to break this trend, LCD, along with other NGOs, the in Jordan Jordanian Ministry of Health and the WHO, tailors school campaigns specifically for children and teenagers—ideally to intervene before they start smoking and create smoke-free schools. Young children The WHO estimates that nearly 63% of men and 10% of women use are taught the hazards of tobacco through interactive games and tobacco in Jordan, giving it the highest tobacco prevalence rate puzzles, while programmes for teenagers include testing of CO2 in the Middle East. Moreover, with close to one-third of adolescent levels in the blood and counselling on how to stop smoking. “Many boys and one-quarter of adolescent girls smoking cigarettes or former youth smokers become advocates against tobacco. This is the water pipes, Jordan’s smokers appear to be starting earlier than most effective way to change habits, to have youth delivering the almost anywhere else in the region (only Lebanon has a higher message to other youth,” Ms Hammad says. youth tobacco prevalence, according to national surveys). “What Also at the forefront of the fight to end youth tobacco use in scares me most is that the age at which they start smoking is Jordan is enforcement of existing legislation. Until now, people getting increasingly younger,” says Mawya Zawawi Hammad, have smoked anywhere despite a ban on smoking in public places general manager of Lina Creative Development (LCD), an NGO that since 1977. Vendors and retailers have sold tobacco to under-age targets Jordanian youth in anti-tobacco media campaigns. “You see adolescents with impunity. “Children have had easy access to youngsters 9 to 10 years old starting to smoke.” tobacco. Even young kids can go to a small corner shop and buy Jordan’s adolescents begin smoking, Ms Hammad says, by cigarettes,” confirms Ms Hammad. But pressure is mounting to fine following the examples of their adult role models. “Their parents, smokers caught lighting up in public places (including schools, their teachers, their popular friends, rock stars—everyone smokes. hospitals and government buildings) and people caught selling It is considered to be a cool thing. If you don’t smoke, you feel tobacco products to minors. socially excluded.” Despite some slow progress, cigarette smoking and the use of water According to the American Cancer Society, almost 90% of adult pipes remain widespread, if not culturally sanctioned, in Jordan. While smokers started at or before 19 years of age, making age the crucial the ultimate goal is eradication of both youth and adult tobacco use, link in a lifelong chain of addiction. Ms Hammad acknowledges, “we still have a long way to go”.

have a party you have to have a water pipe.” Dr Monique Chaaya, a professor at the American University of Beirut, says that up to 60% of 16-19- year-olds in the Middle East have tried the water pipe. “It’s becoming an epidemic,” she says, claiming that between 1999 and 2007 water pipe usage in the Middle East rose by 200% among women and 60% among men. Efforts to stop the spread of water pipes are just beginning. In general, anti-water pipe policies lag behind other anti-tobacco programmes, largely because the water pipe is culturally acceptable. Water pipes fall under the bans on public smoking, but they are rarely enforced. Children are often encouraged to smoke by their parents, and although doctors in the region might advise on the health risks of smoking, they are not as adamant about the risks of pipe smoking. “We are doing a lot of research on water pipes, the smoke and its composition,” confirms Dr Chaaya. “We have to come up with evidence, and we have to convince the public of the dangers. We don’t want to have to wait for another big global study. The more we talk about it, the more it will filter through to policymakers.”

Government action: Giving with one hand, taking away with the other

n 2007, Egypt adopted landmark legislation that outlawed the sale of tobacco to minors, banned Ismoking from indoor areas and added 10% to the cost of cigarettes. The experts we interviewed say the government is a leader in the region. “For a lot of the Middle East region, Egypt is a point of reference,” says Armando Peruga, Geneva-based programme manager for the WHO’s Tobacco Free Initiative. And yet, according to one official we spoke to in Egypt, the finance and health ministries are at odds over tobacco policy, and the result is often paralysis. Other ministries are disposed to anti-tobacco policies, but they have more pressing priorities, this official notes. The government’s cross-ministry anti-tobacco committee has convened only once in the past 18 months. “The government is not yet fully committed,” he says. This kind of ambivalence on the part of elected officials is rife throughout MEA. On the one side are the finance ministers, who focus on the jobs and revenue that depend on tobacco. The tobacco industry, whose lobbyists often have the ear of finance ministries, emphasise the jobs that would be lost if the industry were hobbled. One tobacco industry representative in Nigeria claims that about 5,000 people are directly employed by tobacco companies in Nigeria, in addition to about 1,000 farmers who rely on the industry for their livelihoods. He calculates that further indirect employment, such as jobs in distribution, stocking and retailing, account for over 1 million people in Nigeria. On the other side are the health ministers, who emphasise the long-term consequences to the nation’s health, and, incidentally, its finances, since governments are ultimately responsible for dealing with a wave of smoking-related chronic diseases. In 2007, in papers filed for a suit against BAT, Phillip Morris and the Tobacco Institute, the Nigerian government estimated there were more than 9,527 tobacco-related cases in state-run hospitals during the year. Moreover, a survey of 26 state-run hospitals showed that two people die each day from tobacco-related illnesses. It estimated that the state spends N216,000 (US$1,457) on each case of tobacco-related diseases and the individual spends another N70,000 (US$472). The problem is multiplied in countries where the government either owns or controls tobacco manufacturing. In Tunisia, government manufacturing translates into 17,000 jobs. One official we spoke to acknowledges the brutal truth: “The government will lose money if Tunisians smoke less.”

It seems paradoxical—governments selling cigarettes while attempting to ban them at the same time. Our experts say the issue is more complicated. “It’s always a debate,” says Mr Peruga. “On the one hand, it’s a source of revenue; on the other, because the tobacco companies are government-owned, they are usually more responsive to tobacco control policy. It has pros and cons.” The best tools, blunted Three of the most effective policies for reversing prevalence trends are advertising bans, smoke-free public places and price hikes, with price increases having proved particularly effective in discouraging youth smoking. All three policies create what Dr Rima Nakkash, a professor at the American University of Beirut, calls an enabling environment for tobacco control. “You can’t change behaviour unless you have an enabling environment,” she says. “Knowledge is not sufficient for people to change their behaviour. We are aware of a lot of doctors who know that smoking is bad for you, and still smoke.” South Africa is a prime example of the positive effects of public policy. The WHO report lauds the country as a success story. Prevalence rates dropped after strict bans were enforced, and the organisation says that after taxes were increased by 250% during the 1990s, consumption fell by 5-7% for every 10% increase in the price of cigarettes. Among the ten countries in our sample, three—Jordan, South Africa and the UAE—have “complete” advertising bans, according to the WHO, which encompass all national television and radio, local magazines and newspapers, billboard and outdoor advertising, and at the point of sale. Enforcing the legislation is often far from complete, however. The WHO, for example, gives both the UAE and South Africa a score of 7 out of 10 for enforcement, which means that, in practice, tobacco advertisements

Influence on a shoestring capital city of Abuja a smoke-free zone. “This was a great success for organisations working in the area of tobacco control, and symbolically very important since Abuja is considered the centre of When governments have acted, it has often been in response our country,” says Mr Oluwafemi. “Now we are working towards a to pressure applied by charities and other non-governmental national anti-smoking law.” organisations (NGOs), and their influence throughout the region is Often run on shoestring budgets and staffed by volunteers, growing. “Our objectives are twofold—to pressure governments to put NGOs’ struggle against tobacco companies is a modern-day David laws into place that regulate tobacco companies and to raise public and Goliath tale. But support from the international community, awareness,” says Akinbode Oluwafemi, programme manager and head such as the commitment in 2008 of the Bloomberg and Gates of the tobacco control campaign at Friends of the Earth Nigeria. foundations of US$500m to support global anti-smoking efforts, is NGOs have employed a range of tactics to achieve these ends. In giving NGOs a much-needed boost. “We are beginning to see more Jordan, the Lina Creative Development Group runs school awareness support for anti-tobacco efforts in the continent,” confirms Mr campaigns about the risks of tobacco use, while the American Oluwafemi, “although there is still a great need for funds in many Cancer Society programme for a smoke-free environment in Tunisia countries.” (Mr Oluwafemi’s organisation won a US$100,000 grant focuses on training, assistance and workshops for doctors and from the Bloomberg foundation earlier this year.) state and private companies. “We raise public awareness about the “There is now a career path for tobacco control in low- and dangers of tobacco use on a local level, by getting involved with middle-income countries, in the WHO and NGOs,” adds Dr Mackay people and communities,” explains Dr Ayoub, co-ordinator of the of the World Lung Foundation. “Before, hospital medicine was American Cancer Society’s efforts in Tunisia. seen as more exciting than prevention and public health. I have Anti-tobacco proponents in Nigeria had a tantalising taste received death threats from smokers’ rights groups. It’s certainly of victory last year when the federal government designated the not boring.”

10 © The Economist Intelligence Unit Limited 2009 Tomorrow’s regular customers? Stamping out tobacco use in the Middle East and Africa

frequently find their way into newspapers and onto the air waves, despite the legal embargoes. Only Jordan has a complete advertising ban and scores a perfect 10 on the WHO’s enforcement scale. “I think Jordan is a regional leader in this regard,” says Dr Hiba Ayoub, head of the tobacco control unit at the Jordanian Ministry of Health. “Laws banning advertising are strictly enforced, with heavy sanctions involved. Car races in Amman used to be sponsored by Marlboro, but no longer. You will never find a billboard or an advertisement in local newspapers.” Jordan is a bright spot for advertising bans. But in most countries in MEA, the ambivalence within governments leads to contradictory policies. Bans are enacted but not well enforced, and taxes are levied but not at levels high enough to have a serious impact on prevalence. In the meantime, regional policy remains scattered. “There is a lack of enthusiasm by the [Saudi Arabian] government,” says one doctor and expert we spoke to in Riyadh. “They passed a smoking ban but it isn’t enforced. There is a lack of will.” Smoking in public is common throughout MEA and second-hand smoke wafts freely through hospitals, schools and restaurants. None of the countries we examined had more than moderate policies in place, and several had no policies at all. Even the countries with strict bans on the books, such as Egypt and Morocco, fail to enforce them adequately. Jordan, which cracks down so effectively on advertising, has what the WHO describes as a “minimal” policy and is given a score of 4 out of 10 on

Status of taxes, cigarette prices, advertising bans, smoke-free legislation, health warnings and cessation programmes in selected countries

Price Tax Advertising ban Smoke-free environments Health Cessation and enforcement and enforcement warnings programmes Algeria $1.61 49% Minimal: 5 Minimal: 3 Minimal Minimal Egypt $1.42 58% Moderate: 10 Moderate: 3 Moderate Moderate Jordan $4.16 39% Complete: 10 Minimal: 4 Minimal Moderate Lebanon $.50 48% None None Minimal Moderate Morocco $5.32 50% Moderate: no data Moderate: no data Minimal Moderate Nigeria $2.31 28% No policy Moderate: 0 No policy Moderate Saudi Arabia $1.65 Data not available Moderate: 5 Minimal: 0 No policy Moderate South Africa $5.15 32% Complete: 7 Moderate: 5 Moderate Moderate Tunisia $3.72 Data not available Moderate: 8 None Minimal Moderate United Arab Emirates $.36 Data not available Complete: 7 Moderate: 3 No policy Moderate Note: The prices of cigarettes in the above table are based on the price of a 20-pack of the most widely consumed brand in US dollars at purchasing power parity in 2006. Tax rates do not reflect any changes subsequent to publication of the WHO mpower report. Advertising bans, smoke-free environments, health warnings and cessation programme policies were rated on a four-point scale: no policy, minimal policy, moderate policy and complete policy. The scores for the level of enforcement of advertising bans and smoke-free environments were measured on a scale from 0 to 10 by the WHO.

Source: WHO Report on the Global Tobacco Epidemic, 2008: The MPOWER package, World Health Organisation.

11 © The Economist Intelligence Unit Limited 2009 Tomorrow’s regular customers? Stamping out tobacco use in the Middle East and Africa

enforcement. Algeria’s ban is not enforced anywhere, adds Dr Hamdi-Cherif of the University of Setif. “The only place in Algeria where people don’t smoke is on planes,” he says. Experts acknowledge that public support for smoking bans, which is so crucial to their success in Western countries, is far from all-encompassing in MEA. Compounding the problem is the social disparity between those charged with enforcing the bans and those who are flouting the rules. It would be inconceivable in many countries, for example, for a poorly paid mall security guard, who is often an immigrant, to approach nationals about refraining from lighting up. The latest comparable figures for cigarette pricing and taxes, measured in 2006 at US dollar parity, range from a low of 50 US cents for a pack of 20 cigarettes in Lebanon to a high of US$5.15 per pack in South Africa and US$5.32 in Morocco. According to the WHO, tax rates are highest in Egypt, at 58%, and lowest in Nigeria, at 28%. Generally, however, in most countries smoking remains affordable and accessible. Cigarette taxes, which do so much to fight teen smoking, are undermined by cheap local brands, cigarettes sold by the stick, as well as smuggling and black markets. In Saudi Arabia, according to the WHO, the price of a 20-pack of a leading international brand sells for about US$1.65— unacceptable according to a Saudi Arabian doctor we spoke to for the report. “The price is dirt cheap,” he says. “That is what promotes smoking among high school boys and girls. It’s as cheap as a cup of coffee or a sandwich.” He also points the finger at regional agreements that he believes provide an excuse for inaction. Tobacco taxes require the agreement of all six nations of the Gulf Co-operation Council (GCC). “If one country votes against an increase in the price of tobacco, the price is not increased,” he says.

12 © The Economist Intelligence Unit Limited 2009 Tomorrow’s regular customers? Stamping out tobacco use in the Middle East and Africa

Clearing the air: Outlook and future challenges

ven if the most optimistic projections for smoking rates and population growth in MEA are Eaccepted, it is likely that there will be several million more smokers in the region by 2030. Region- specific estimates for the resulting healthcare burden are thin on the ground, but data in the West suggests the bill could be staggering. In the US, for example, according to the Centers for Disease Control, each adult smoker currently accounts for US$1,623 of extra medical spending per year. Research by the British Heart Foundation found that treating smoking-related diseases costs the UK’s National Health Service (NHS) £5bn per year, amounting to about 5% of the entire NHS budget. Whereas in China, a study conducted by the China Centre for Economic Research estimated that the tab for treating Chinese smokers was Rmb166.6bn (US$24.4bn) or about 1% of the country’s GDP. All of the ten countries we examined for this report face challenging demographics. Even in countries with relatively low adult prevalence rates, such as Nigeria, youth smoking and population growth are driving up absolute numbers. From a public health perspective, it is clear that smoking rates, especially among children, cannot simply remain flat; they must come down.

Number of smokers in selected countries, with all other factors remaining equal: 2010 and 2030 (m) 2010 2030 18 18

16 16

14 14

12 12

10 10

8 8

6 6

4 4

2 2

0 0 Algeria Egypt Jordan Lebanon Morocco Nigeria Saudi Arabia South Africa Tunisia United Arab Emirates Sources: United Nations Population Division; World Health Organisation; Economist Intelligence Unit.

13 © The Economist Intelligence Unit Limited 2009 Tomorrow’s regular customers? Stamping out tobacco use in the Middle East and Africa

Despite the depressing statistics and high odds, campaigners remain surprisingly optimistic that they can slow or reverse the trends. They point to the fact that governments are responding to the increasingly organised efforts of NGOs and their advocates within the health ministries. In Jordan, for example, where smoking rates are among the highest in the region, they say that recently implemented bans have yet to have a full impact on prevalence. The public too is responding. Our experts say they have been pleasantly surprised in recent months to see people in restaurants ask the person next to them to put out their cigarette. In Algeria, Dr Hamdi-Cherif compares his anti-tobacco work to a successful public awareness campaign to promote seatbelts in Algeria. “There isn’t a single driver who drives without a seatbelt,” he says. “When the political will is there, no matter what the subject, it works very well.” To drive momentum, campaigners will focus on three fronts. The first is collecting unassailable data that allow for comparison across countries and time. This will support communication and lobbying. The second is continuing to back measures that have proved to reduce smoking elsewhere: enforcement of existing bans, rallying support for new ones and efforts to raise the price of tobacco. The third is challenging the popularity and reputation of the water pipe. “Our future plan is to focus on young people, and create a highly educated population that is aware of the dangers of smoking,” says Dr Al-Maidoor in the UAE. “If we have collaboration between the different authorities in the country, and if the law is properly applied, it will help to cut smoking levels dramatically.” In the West, a similar concerted effort led to a tipping point, when a confluence of government policies influenced the public, which in turn supported ever more restrictive laws and regulations, and this cycle continues. Dr Yves Martinet, president of France’s National Committee Against Tobacco, describes the process in his country. “The key success factor in France was that 80-85% of the population was in favour of a ban before it came into effect,” he says. “The hard work has to be done before the law comes into effect in order to change people’s minds. Once the population is with you, the ban will be effective.” If it can happen in the West, it can happen in MEA, say campaigners. “There is an understanding that it is not enough to pass a law,” says Mr Peruga of the WHO’s Tobacco Free Initiative. “Social norms have to change. The law might help, but that is not the only instrument.”

14 © The Economist Intelligence Unit Limited 2009 Appendix Tomorrow’s regular customers? Country profiles Stamping out tobacco use in the Middle East and Africa

Appendix: Country profiles

Note about sources: The source for prevalence rates, cigarette prices, taxes and bans is the World Health Organisation (WHO) report, WHO Report on the Global Tobacco Epidemic, 2008: The MPOWER package. The source for the country summary narratives is Economist Intelligence Unit interviews with country tobacco experts in the WHO, health ministries and non-governmental organisations (NGOs). Note about definitions: Prevalence data are sourced from the WHO’s age-standardised estimates to a 95% confidence interval, for the purposes of comparison across countries. Men and women are defined as adults over the age of 15 years. Youth smoking rates are for children in the 13-15 age bracket. Adult prevalence rates are for “current smoking”, which is defined by the WHO as “smoking at the time of the survey, including daily and non-daily smoking”. The rates reflect “smoking any form of tobacco including cigarettes, cigars, pipes, bidis, etc.” Youth figures include the percentage of those who “consumed any smokeless or smoked tobacco product at least once during the last 30 days prior to the survey”. Prevalence rates from the WHO are based on self-reporting of individual tobacco consumption. The prices of cigarettes in the following tables are based on the price of a 20-pack of the most widely consumed brand in US dollars at purchasing power parity in 2006. Tax rates do not reflect any changes subsequent to publication of the WHO report. Advertising bans, smoke-free environments, health warnings and cessation programme policies were rated on a four-point scale: no policy, minimal policy, moderate policy and complete policy. The scores for the level of enforcement of advertising bans and smoke-free environments were measured on a scale from 0 to 10 by the WHO.

15 © The Economist Intelligence Unit Limited 2009 Appendix Tomorrow’s regular customers? Country profiles Stamping out tobacco use in the Middle East and Africa

Algeria

Prevalence rates Men: 29.9% Women: 0.3% Boys (13-15 years): Data not available Girls (13-15 years): Data not available

Prices, taxes and bans Price in US dollars for a pack of 20 cigarettes: $1.61 Tax rate: 49% Advertising ban: Minimal Smoke-free environments: Minimal Health warnings: Minimal Cessation programmes: Minimal

Country summary Prevalence is falling among adults, but rising among young people. A 2007 study found that one in two boys in the 10-17 age bracket smoked regularly and smoking is common at university. According to the Global Youth Tobacco Survey of 2007, 12.8% of 13-15-year-olds smoke. (The above table shows “Data not available” because the WHO was unable to adjust the survey data to reflect a uniform rate comparable across countries for 13-15 year olds.) Nargile smoking is a new phenomenon, but in the past three years its prevalence has increased rapidly and it is now very fashionable, particularly among young people.

16 © The Economist Intelligence Unit Limited 2009 Appendix Tomorrow’s regular customers? Country profiles Stamping out tobacco use in the Middle East and Africa

Egypt

Prevalence rates Men: 28.7% Women: 1.3% Boys (13-15 years): 16% Girls (13-15 years): 7.6%

Prices, taxes and bans Price in US dollars for a pack of 20 cigarettes: $1.42 Tax rate: 58% Advertising ban: Moderate Smoke-free environments: Moderate Health warnings: Moderate Cessation programmes: Moderate

Country summary Our experts believe that WHO figures for men are under-reported, but the figures for women are accurate. Prevalence is estimated to be growing by 6-7% per year. Among university students, the prevalence rate is believed to be close to 50%. In general, prevalence is falling among older people but increasing among the young. Smoking by young females is looked upon with contempt in rural areas, but it is increasingly popular in urban areas, especially in the capital, Cairo. Water pipes are culturally embedded and very popular.

17 © The Economist Intelligence Unit Limited 2009 Appendix Tomorrow’s regular customers? Country profiles Stamping out tobacco use in the Middle East and Africa

Jordan

Prevalence rates Men: 62.7% Women: 9.8% Boys (13-15 years): 31.6% Girls (13-15 years): 24%

Prices, taxes and bans Price in US dollars for a pack of 20 cigarettes: $4.16 Tax rate: 39% Advertising ban: Complete Smoke-free environments: Minimal Health warnings: Minimal Cessation programmes: Moderate

Country summary Despite a strict ban on tobacco advertising, a higher cost of cigarettes than anywhere else in the region, health warnings on labels and recent bans on smoking in public places, Jordan has a surprisingly high smoking rate, especially among men. A growing concern is smoking among children, some as young as 9 years. Jordan’s prevalence rates are far higher than its neighbours. Smoking plays an important part in social, family and community life. Some of our experts suggest that after a period of fast growth, tobacco consumption is about to peak in Jordan, possibly in the next three years. The resolve of the government and of NGOs is growing and enforcement of public bans, particularly in restaurants, is expected to have a profound effect.

18 © The Economist Intelligence Unit Limited 2009 Appendix Tomorrow’s regular customers? Country profiles Stamping out tobacco use in the Middle East and Africa

Lebanon

Prevalence rates Men: 29.1% Women: 7% Boys (13-15 years): 65.8% Girls (13-15 years): 54.1%

Prices, taxes and bans Price in US dollars for a pack of 20 cigarettes: 50 US cents Tax rate: 48% Advertising ban: None Smoke-free environments: None Health warnings: Minimal Cessation programmes: Moderate

Country summary The tobacco industry has far-reaching influence in Lebanon and supports a number of other sectors such as advertising, entertainment and media. Local representatives of international tobacco companies are powerful businesspeople who have access to politicians and a strong lobbying capacity. Prices of cigarettes, cigars and other forms of tobacco in Lebanon are some of the cheapest in the world. Cuban cigars are cheaper in Lebanon than they are in Cuba. This is cited by our experts as being one of the key drivers behind smoking in Lebanon. Another driver is the normality of smoking in Lebanon. Bans in restaurants or bars are virtually non-existent and tobacco brands sponsor sports events, entertainment and live concerts.

19 © The Economist Intelligence Unit Limited 2009 Appendix Tomorrow’s regular customers? Country profiles Stamping out tobacco use in the Middle East and Africa

Morocco

Prevalence rates Men: 29.5% Women: 0.3% Boys (13-15 years): 12.5% Girls (13-15 years): 8.2%

Prices, taxes and bans Price in US dollars for a pack of 20 cigarettes: $5.32 Tax rate: 50% Advertising ban: Moderate Smoke-free environments: Moderate Health warnings: Minimal Cessation programmes: Moderate

Country summary Morocco is probably the best performing of the four North African markets examined in our survey with regard to bans and enforcement. It has legislation and implementation. Lalla Salma, the First Lady of Morocco, is influential in supporting anti-smoking campaigns. Nargile smoking is starting to become a problem, however. It was not prevalent in Morocco before a few years ago, but there are an increasing number of places dedicated to nargile smoking.

20 © The Economist Intelligence Unit Limited 2009 Appendix Tomorrow’s regular customers? Country profiles Stamping out tobacco use in the Middle East and Africa

Nigeria

Prevalence rates Men: 13% Women: 1.2% Boys (13-15 years): 22.6% Girls (13-15 years): 11.2%

Prices, taxes and bans Price in US dollars for a pack of 20 cigarettes: $2.31 Tax rate: 28% Advertising ban: No policy Smoke-free environments: Moderate Health warnings: No policy Cessation programmes: Moderate

Country summary There are no comprehensive data on tobacco smoking in Nigeria, and our experts stressed the need to build an accurate national statistics database on consumption, as the country’s National Bureau of Statistics does not cover tobacco consumption. A number of local studies, however, suggest that the problem is on the rise. One survey of Katsina state in the last five years estimated that 26% of adults are smokers, but there was no peer review mechanism. If this is the case, it would mean that there are twice as many smokers in northern states as there are in the south. There is a particularly high prevalence of smoking among young people and seniors. A 2008 survey of four major cities in Nigeria revealed that 35% of respondents were exposed to second-hand smoke.

21 © The Economist Intelligence Unit Limited 2009 Appendix Tomorrow’s regular customers? Country profiles Stamping out tobacco use in the Middle East and Africa

Saudi Arabia

Prevalence rates Men: 25.6% Women: 3.6% Boys (13-15 years): 13.2% Girls (13-15 years): Data not available

Prices, taxes and bans Price in US dollars for a pack of 20 cigarettes: $1.65 Tax rate: Data not available Advertising ban: Moderate Smoke-free environments: Minimal Health warnings: No policy Cessation programmes: Moderate

Country summary Health professionals cited Saudi Arabia’s membership of the Gulf Co-operation Council (GCC) as being a hindrance to introducing new legislation, as laws on issues such as taxation would require the agreement of all members of the GCC. The tobacco industry has less influence in Saudi Arabia than in other countries covered in this report. Tobacco industry associations are banned. Culturally, smoking is not acceptable among the older generations, although it is on the increase among younger people. Smoking is also on the increase among women, but again this is not acceptable in public. The use of the water pipe is also rising but has been banned in the capital, Riyadh. It is, however, available for use in Jeddah and other cities.

22 © The Economist Intelligence Unit Limited 2009 Appendix Tomorrow’s regular customers? Country profiles Stamping out tobacco use in the Middle East and Africa

South Africa

Prevalence rates Men: 27.5% Women: 9.1% Boys (13-15 years): 29% Girls (13-15 years): 20%

Prices, taxes and bans Price in US dollars for a pack of 20 cigarettes: $5.15 Tax rate: 32% Advertising ban: Complete policy Smoke-free environments: Moderate Health warnings: Moderate Cessation programmes: Moderate

Country summary An estimated 22% of adults (men and women) over the age of 15 are smokers; this figure is down from 35% of the population of smokers in 1990. South Africa has been successful in lowering prevalence rates through applying restrictive legislation and increasing taxes. The main driver of smoking in the South African market is cultural; social peer pressure is also a strong driver, particularly among younger smokers. The tobacco industry promotes cigarettes indirectly, mainly through event sponsorship and parties in which cigarettes are given free to attendees. Further data on prevalence are needed, according to our experts. The Ministry of Health last published a comprehensive report on smoking in South Africa in 2003 and is now awaiting publication of further research carried out in 2008.

23 © The Economist Intelligence Unit Limited 2009 Appendix Tomorrow’s regular customers? Country profiles Stamping out tobacco use in the Middle East and Africa

Tunisia

Prevalence rates Men: 51% Women: 1.9% Boys (13-15 years): 24.9% Girls (13-15 years): 6%

Prices, taxes and bans Price in US dollars for a pack of 20 cigarettes: $3.72 Tax rate: Data not available Advertising ban: Moderate Smoke-free environments: None Health warnings: Minimal Cessation programmes: Moderate

Country summary A presidential decree has made 2009 the year to combat smoking, and ministers have their work cut out. Tunisia has the highest smoking rate in Africa. The official rate among women is only about 2%, but some studies suggest it could be as high as 20%. Overall, consumption has increased in the last ten years. Prevalence among women and children is increasing; smoking is becoming more socially acceptable for women, particularly in urban areas. School teachers smoke in schools and smoking by children is tolerated in proximity to schools. People smoke in hospitals, including doctors. There is some optimism that increasing awareness in recent years and government leadership will help prevalence rates to fall in the next 5-10 years.

24 © The Economist Intelligence Unit Limited 2009 Appendix Tomorrow’s regular customers? Country profiles Stamping out tobacco use in the Middle East and Africa

United Arab Emirates

Prevalence rates Men: 26.1% Women: 2.6% Boys (13-15 years): 25.2% Girls (13-15 years): 13.2%

Prices, taxes and bans Price in US dollars for a pack of 20 cigarettes: 36 US cents Tax rate: Data not available Advertising ban: Complete Smoke-free environments: Moderate Health warnings: None Cessation programmes: Moderate

Country summary Smoking is embedded in the culture, and the water pipe in particular is seen as a social pastime. Cigarettes are cheap and laws surrounding smoking are relatively lax compared with many Western jurisdictions. The UAE traditionally lacks coherent rules and education around the dangers of tobacco, but there is evidence that this is now changing. The authorities are in the process of putting in place policies and practices in line with WHO initiatives. The “No Tobacco Campaign” was launched this year by ExHealth, a healthcare company, in conjunction with the Ministry of Health and Dubai Healthcare City. It aims to secure 10,000 pledges from individuals to give up smoking by the end of the year. The campaign involves highlighting the dangers of smoking through methods including street plays, talks and leaflet distribution.

25 © The Economist Intelligence Unit Limited 2009 While every effort has been taken to verify the accuracy of this information, neither The Economist Intelligence Unit Ltd. nor the sponsor of this report can accept any responsibility or liability for reliance by any person on this white paper or any of the information, opinions or conclusions set out in this white paper.

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