Monshi and Ibrahim Substance Abuse Treatment, Prevention, and Policy (2021) 16:57 https://doi.org/10.1186/s13011-021-00393-8 RESEARCH Open Access Implementation of tobacco control measures in the Gulf Cooperation Council countries, 2008–2020 Sarah S. Monshi1,2* and Jennifer Ibrahim1 Abstract Background: The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) was developed to assist nations in reducing the demand and supply of tobacco. As of 2020, 182 nations joined the FCTC, agreeing to implement the recommended tobacco control measures. The Gulf Cooperation Council (GCC) countries, including Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates (UAE) ratified the WHO FCTC by August 2006. Given the unique political, cultural, and religious context – and known tobacco industry efforts to influence tobacco use- in these nations, a careful examination of the translation of FCTC measures into policy is needed. This study aimed to assess the implementation of FCTC tobacco control measures at the national level within the six GCC countries. Method: We collected and coded the FCTC measures that were implemented in the GCC countries. We examined trends and variations of the implementation between 2008 and 2020. Results: GCC countries implemented most FCTC measures targeting the demand for and supply of tobacco, with some variation among countries. Bahrain and Qatar were more comprehensively implementing FCTC measures while Kuwait and Oman implemented the least number of the FCTC measures. Implementing measures related to tobacco prices and eliminating the illicit tobacco trade has slowly progressed in GCC countries. All GCC countries entirely banned smoking in workplaces while three countries implemented a partial ban in restaurants. Only Oman has restrictions on tobacco ads shown in media. There is progress in implementing FCTC measures related to tobacco packaging, cessation, and sale to minors in most GCC countries. Conclusions: Given the influence of the tobacco industry in the Gulf region, the findings suggest a need for ongoing surveillance to monitor the proliferation of tobacco control measures and evaluate their effectiveness. Efforts required to address tobacco use should correspond to the unique political and cultural background of the GCC countries. Keywords: Tobacco control measures, Anti-tobacco policy, Smoking, Tobacco use, Gulf Cooperation Council, Framework convention on tobacco control * Correspondence: [email protected] 1Department of Health Services Administration and Policy, College of Public Health, Temple University, 1301 Cecil B. Moore Avenue, Philadelphia, PA 19122, USA 2Department of Health Services Administration, Umm Al-Qura University, Mecca, Saudi Arabia © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Monshi and Ibrahim Substance Abuse Treatment, Prevention, and Policy (2021) 16:57 Page 2 of 10 Background Arabia, and UAE, with a growing number of female Global tobacco use youths who were willing to initiate tobacco use [12]. Tobacco use is responsible for more than eight million worldwide deaths annually [1] and is the greatest risk Framework convention on tobacco control factor for many preventable diseases, including cancers In response to the growing tobacco use, the World and cardiovascular diseases. The harmful effect of to- Health Organization (WHO) introduced the Framework bacco use spreads to non-tobacco users exposed to sec- Convention on Tobacco Control (FCTC) in 2003. The ondhand smoke (SHS), causing preventable diseases FCTC is an international treaty to assist nations in over- among non-tobacco users. Globally, there are more than coming the negative consequences of tobacco use one million premature deaths per year due to SHS- through evidence-based measures intended to reduce related disease; among them 65,000 are children [1]. The the global demand and supply of tobacco (Table 2)[13]. global economic cost of tobacco use in 2016 accounted The FCTC measures targeting the demand for tobacco, for $1.4 trillion [2], including costs associated with pre- such as increasing tobacco taxes, protecting people from mature death, treating chronic diseases, and loss of SHS, and raising public awareness against the harmful workplace productivity [3]. effects of tobacco. In contrast, the FCTC measures tar- geting tobacco supply include eliminating illicit tobacco trade and restricting the sale of tobacco to minors. As of Tobacco use in the Gulf Cooperation Council countries 2020, 182 countries have joined the FCTC, agreeing to Despite significant efforts to control tobacco use world- work towards implementing the recommended tobacco wide [4], one area of the globe where tobacco use con- control measures [14]. tinues to be a significant problem is in the Middle East. In 2008, building on the framework provided in the The Gulf Cooperation Council (GCC) is a political and FCTC, the WHO developed the “MPOWER” policy economic union of six countries: Bahrain, Kuwait, package with specific measures on tobacco’s demand Oman, Qatar, Saudi Arabia, and the United Arab Emir- side. MPOWER stands for (M) monitor tobacco use, (P) ates (UAE) located in the Middle East. They share simi- protect from exposure to SHS, (O) offer help to quit to- lar economic and social characteristics (Table 1)[5]. bacco, (W) warn about the danger of tobacco, (E) en- They experienced similar economic growth due to oil force ban on advertisement, sponsorship, and discovery during the 1930 s [6]. The region is the origin promotion, and (R) raise tobacco tax. Four years after of the Islamic religion, which strongly impacts the soci- the creation of MPOWER, the WHO introduced the eties’ values. Islam does not clearly state that tobacco protocol to eliminate illicit tobacco trade as an inter- use is forbidden. Instead, it encourages individuals to national treaty based on FCTC Article 15, which in- preserve their overall health [7]. cludes measures to regulate the manufacturing, The estimated prevalence of tobacco smoking among shipping, sale, and distribution of tobacco products. Art- adults in 2017 ranged from 19.3 % in Kuwait to 7.8 % in icle 15 entered into force in September 2018 [15, 16]. Oman, with a higher prevalence among males than fe- Evidence shows that the implementation of FCTC males (Fig. 1)[8, 9]. The economic burden of smoking measures leads to promising outcomes [17]. One of the and SHS in GCC countries accounted for $34.5 billion key aspects of FCTC measures is changing the physical in 2016 [10]. The projected trend of adult tobacco use in environment that influences psychosocial and behavioral GCC countries indicates a steady increase in tobacco use factors associated with tobacco use [18, 19]. Implement- among adult males compared to females [11]. Moreover, ing FCTC measures such as raising tobacco taxes and the trend of susceptibility to initiating tobacco use public awareness affects attitudes and perceptions about among youth, aged 13 to 15 years, has increased in mul- tobacco use, while a smoke-free policy protects individ- tiple GCC countries including Oman, Qatar, Saudi uals from exposure to SHS and creates anti-social norms Table 1 Key characteristic of GCC countries Bahrain Kuwait Oman Qatar Saudi Arabia UAE Geographic Size (Thousand square km) 0.77 17.82 309.5 11.6 2000 71.02 Capital Manama Kuwait Muscat Doha Riyadh Abu Dhabi Primary Language Arabic Arabic Arabic Arabic Arabic Arabic Population (Million People) 1.37 3.97 4.16 2.44 31.52 8.26 Gross Domestic Product (Billion US Dollar) 31.13 114 69.8 164.64 646 370.3 Per Capita Gross Domestic (Thousand US Dollar) 22.71 28.7 16.8 67.5 20.8 48.33 Source: Secretariat General of the Cooperation Council for the Arab States of the Gulf [5] Monshi and Ibrahim Substance Abuse Treatment, Prevention, and Policy (2021) 16:57 Page 3 of 10 Fig. 1 Shows age-standardized estimated prevalence of current tobacco smoking among adults (Age ≥ 15) who smoke tobacco daily and occasional in GCC countries [9] toward tobacco use [18]. Other FCTC measures such as protocol of eliminating illicit trade in tobacco products banning tobacco ads and regulating tobacco sales and (Fig. 2)[14, 16]. However, the literature shows a gap in trades prevent tobacco industry interference and limit reporting the progress of FCTC implementation. A par- the industry’s activities aimed at increasing tobacco sales ticular limitation in the existing literature is that most [20]. Consequently, the comprehensive implementation studies reported the