Context
In the late seventies, there was widespread exposure to second-hand smoke in Egypt, leading to increased disability and premature death related to smoking. Urgent action was required to control the smoking epidemic through legislative measures. Egypt implemented various initiatives in three phases of legislation development and adoption in 1981, 1993 and 2002, which incorporated most of the demand-side measures of the WHO Framework Convention on Tobacco Control (FCTC), even before Egypt's official ratification on 25 February 2005. However, certain gaps remained in relation to each measure.
The initial tobacco control legislation was enacted in Egypt in 1981, marking a significant milestone achieved by the parliamentary health committee, led by a dedicated cardiologist. This law prohibited smoking in public transportation and both open and enclosed public spaces. However, the specification of these public places was left to the discretion of the Minister of Health. Violations of the law carried penalties, including imprisonment for up to one week and fines ranging from EGP 5 to EGP 20, or both. Additionally, the Labour Law 1981/137 prohibited smoking during work hours or in workplaces, outlining administrative penalties for violators. Furthermore, the Environmental Affairs Law 1994/4 prohibited smoking in public transportation and emphasized the responsibility of establishment managers to prohibit smoking in enclosed public areas, though with the requirement of designated smoking spaces.
Despite the health committee's efforts, an attempt in 1993 to pass legislation that banned all forms of tobacco advertising in the country was thwarted and undermined due to strong interference from the tobacco industry.
Initiative
Following Egypt's ratification of the WHO FCTC, Law 2007/154 was issued to explicitly highlight the country's commitments under the Convention and amend certain provisions of Law 1981/52. The updated law designated specific public places as smoke-free, including healthcare, educational and governmental facilities, social and sports clubs, and youth centers, with additional places to be determined by the Minister of Health. However, the law and bylaw did not extend to cover restaurants and cafes. Penalties for establishment managers were increased to EGP 1000 to EGP 20 000, while smokers faced fines of EGP 50 to EGP 100. The Minister of Health signed the Executive Bylaw 2010/291 of 1981/52 in 2010, providing clear definitions of closed public places where smoking is prohibited and addressing public transportation. Establishment managers were made responsible for displaying visible no smoking signs, particularly at entrances, indicating the smoking prohibition and the legal consequences for violations.
Several initiatives were implemented to enhance the enforcement of smoke-free provisions. Collaborating with the Ministry of Health and Population, WHO and the International Union Against Tuberculosis and Lung Disease, the National Guidelines for Implementation of Smoke-Free Policies were developed, outlining the implementation procedures in workplaces, healthcare facilities and educational institutions. Additionally, an Initiative for Smoke-Free Health Care Facilities, in partnership with selected nongovernmental organizations, organized two training-of-trainers workshops to educate tobacco control focal points and healthcare facility managers across all governorates. Furthermore, the Smoke-Free Cities Initiative received support from two grants from the Bloomberg Initiative in 2010, focusing on three Egyptian cities (Alexandria, Port Said and Luxor). However, due to the Egyptian Revolution in 2011, the initiative was not fully completed.
Challenges and lessons learnt
In the past, tobacco control efforts faced sustainability challenges due to inadequate funding and limited political support. However, more recently, tobacco control has been integrated into the Presidential 100 Healthy Lives Initiative, offering some hope for sustained efforts. Despite this, tobacco use remains widely accepted within social norms. Challenges persist in achieving high compliance with smoke-free policies, as the enforcement of Egypt's smoke-free law lacks strictness. Certain indoor private workplaces, shopping malls, airports and other public places still permit designated smoking areas. According to the WHO Report on the Global Tobacco Epidemic of 2019, compliance with smoke-free provisions is notably low, scoring 3 out of 10, particularly in governmental facilities, including healthcare and educational establishments. Public transportation shows relatively higher compliance (7 out of 10), largely due to strict enforcement in the underground. The tobacco control law does not explicitly prohibit designated smoking rooms or areas in certain indoor public spaces, such as offices, workplaces and airports. Restaurants and cafes are not covered by the smoke-free law.
The national law does not allocate specific funds for enforcement. Although Law 2007/174 and Executive Bylaw 2010/291 of 1981/52 outline the responsibility of law enforcement personnel, the Tobacco Control Department faces practical challenges in executing these provisions due to limited staff (only 3 members) and the inability to conduct regular nationwide enforcement campaigns. Currently, the Ministry of Interior is responsible for enforcement, responding to complaints and collecting fines, but regular inspections of smoke-free places are not conducted unless prompted by a report or complaint. Collaboration protocols exist between the Ministry of Interior, the Ministry of Health and Population, and the Consumer Protection Agency. However, the coordination between the Tobacco Control Department and various departments within the Ministry of Interior is currently not functioning effectively.
Key lessons learnt from this initiative underscore the importance of local collaboration among different government agencies and international collaboration with funding partners to advance tobacco control measures. It is evident that enforcement of smoke-free legislation is achievable and has been successful in specific settings, such as underground stations, cinemas, airports, select governmental institutions and some private companies.
Impact
The objectives of the tobacco control strategy are to annually decrease the prevalence of current tobacco use among adults by 1% and among youth by 2%, as well as to reduce exposure to second-hand tobacco smoke in public places by 1%. The impact on adult tobacco use and exposure to second-hand smoke in public places appears to be either absent or minimal. However, there has been a decline in tobacco use prevalence among youth, dropping from 15.8% in the Global Youth Tobacco Survey of 2001 to 12.0% in the Global Youth Tobacco Survey of 2009, indicating an indirect influence of the smoke-free policy. Inconsistencies in enforcing the law may be a contributing factor to this outcome.
Next steps
To challenge the normalization of tobacco use, it would be beneficial to establish alternative channels of communication with civil society, female social agents in rural areas (Raaedat Reefeyat) and media personnel. Engaging in a societal dialogue about law enforcement can help raise awareness about the rights of non-smokers in smoke-free environments. This approach may bring together various parties and form coalitions to rejuvenate tobacco control efforts in Egypt. Additionally, it may be effective to raise awareness in educational facilities, healthcare facilities, dental clinics and family medicine centers. For example, educating children in schools, along with their teachers and parents, to become advocates for smoking control and prevention. This can be achieved through collaboration between the ministries of education and higher education and research to update and incorporate awareness programmes into student curricula.
Other steps to enhance compliance with and enforcement of Egypt's smoke-free law include:
Updating legislation on smoke-free places to broaden coverage and compliance by maintaining regular communication with the health committee of the Egyptian parliament.
Enforcing the existing Ministry of Health and Population’s National Guidelines for Implementation of Smoke-Free Policies in all healthcare and educational facilities, workplaces and closed public spaces. This requires collaboration between the Ministry of Health and Population, Ministry of Interior, Ministry of Education and Ministry of Higher Education and Research. The police and authorized inspectors of the Ministry of Health and Population should integrate tobacco control enforcement activities into their routine operations.
Raising awareness through the development of an effective campaign that utilizes traditional broadcast media and emerging digital platforms such as SMS, websites and social media tools like YouTube, Facebook, Twitter, blogging platforms and mobile apps. The campaign should focus on raising awareness about the dangers of second-hand smoking.
Providing training to healthcare workers in primary healthcare centers of the Ministry of Health and Population to routinely inquire about exposure to second-hand smoking and deliver brief interventions, particularly in immunization and antenatal care services.
References
MPOWER measures to reduce demand for tobacco
WHO Framework Convention on Tobacco Control
WHO Report on the Global Epidemic Tobacco 2019
Story originated in 2019.