Context
The Islamic Republic of Iran became a signatory to the WHO Framework Convention on Tobacco Control (FCTC) on 6 November 2005. In line with this commitment, Iran implemented the Comprehensive Act on National Control and Campaign against Tobacco in 2006, accompanied by the Executive Bylaw of the Act in 2007. These legal instruments comprehensively addressed the obligations outlined in the WHO FCTC, covering its substantive articles. Additionally, Iran became a Party to the Protocol to Eliminate Illicit Trade in Tobacco Products in 2018, following parliamentary approval in 2015. Notably, tobacco advertising, promotion and sponsorship are strictly prohibited by law in Iran, and the government is planning to increase penalties for violations in 2020. The National Tobacco Control Headquarters, supported by the resolution of the presidential approval, drafted the National Tobacco Plain Packaging Guidelines in 2019, with finalization of the guidelines currently underway.
To facilitate and support the implementation of the WHO FCTC and the Act, Iran established a national coordination mechanism in 2007, led by the Ministry of Health and Medical Education. The National Tobacco Control Headquarters consists of relevant ministers, key authorities and representatives from active nongovernmental organizations, along with several technical working groups. The enforcement of legislation is supported by Article 14 of the Bylaw, which obliges the Law Enforcement Department (the police) to collaborate with inspectors from the Ministry of Health and Medical Education and the Ministry of Industry. Moreover, the Ministry of Interior oversees law enforcement at the provincial and district levels through its administrative infrastructure.
To reduce tobacco demand, Iran has developed a national tobacco control plan based on the six MPOWER measures. To monitor tobacco use and prevention policies, a schedule has been established and endorsed by the Ministry of Health and Medical Education to ensure regular implementation of the WHO STEPS Survey and Global Youth Tobacco Survey. In line with the Act (Article 13) and the 2008 Bylaw (Articles 1, 7, 8 and 9), smoking in public places is prohibited in Iran, with a broad definition of public places that includes locations open to the public such as religious sites, restaurants, coffee shops and teashops. Additionally, since 2019, the Ministry of Health and Medical Education has operated a toll-free telephone complaint line, enabling the public to report violations of the ban on tobacco consumption in public places and other environmental and occupational health issues, which are then investigated by environmental health inspectors.
In pursuit of universal health coverage, the Ministry of Health and Medical Education launched the Health Transformation Plan in 2014 to reform Iran's health sector. The Health Transformation Plan focuses on primary healthcare reforms, including the integration of a new service package for the prevention and control of noncommunicable diseases and mental health services, including tobacco cessation services starting in May 2014. Throughout the country, approximately 1600 psychologists have been recruited to work in comprehensive health centers to support nationwide tobacco cessation services. Notably, the Ministry of Health and Medical Education has secured the necessary budget to establish a national reference tobacco control laboratory by purchasing sophisticated laboratory equipment (work in progress).
According to the national noncommunicable disease risk factor survey (STEPS 2016), approximately 14.3% of the population aged 18 and older in Iran were smokers (25.16% male and 4.01% female). Unfortunately, in recent years, there has been an increase in waterpipe consumption, particularly among youth and women.
Initiative
To combat the increasing prevalence of smoking, particularly waterpipe smoking among youth and women, the National Tobacco Control Headquarters Secretariat, supported by WHO, introduced the concept of smoke-free cities as an effective strategy to reduce tobacco demand, starting in 2019. Inspired by the successful implementation of tobacco-free initiatives in holy cities like Mecca and Medina, the city of Qom, known for its religious significance, was selected as the first smoke-free city in Iran, followed by Mashhad. With a population of 1.2 million, Qom attracts approximately 20 million pilgrims annually, making it a significant destination.
In July 2019, an advocacy mission took place in Qom, led by representatives from WHO and the Ministry of Health and Medical Education. During the mission, meetings were held with respected religious leaders in Qom to advocate for the Tobacco-free City Initiative in religious sites. The initiative garnered support from these influential religious leaders and subsequently received approval from the province's Governor General, the municipality of Qom, and the Ministry of Health and Medical Education. The plan of action and the monitoring and evaluation framework were then developed in collaboration with relevant stakeholders.
It is worth noting that the initiative in Iran follows a results-based management approach and encompasses various aspects, including reducing the supply of tobacco products and services, with a particular emphasis on waterpipes. It also focuses on strengthening the ban on tobacco advertising, promotion and sponsorship, raising awareness about the dangers of tobacco, protecting individuals from second-hand smoke and providing assistance to quit tobacco use. Given the results-based management approach as the foundation of this initiative, monitoring, evaluation and reporting play a crucial role in its implementation.
Challenges and lessons learnt
The challenges encountered during the implementation of the initiative are outlined below.
The presence and influence of multinational tobacco companies in the country.
Resistance from tobacco and waterpipe suppliers due to economic incentives.
Limited community engagement in tobacco control efforts.
Insufficient taxation on tobacco products.
Reduced access to tobacco cessation medications due to sanctions.
Studies have shown that engaging religious leaders in advocating against tobacco use has had a significant impact on their followers, resulting in a decrease in tobacco consumption among this population. Additionally, the strong political commitment at the national level has allowed the Ministry of Health and Medical Education to successfully adopt a multisectoral and multistakeholder approach. This approach has facilitated the implementation of policy-level interventions, fostering collaborations within and between sectors. Furthermore, involving community leaders, including influential religious leaders, in policy-making processes has been beneficial for tobacco control efforts. Lastly, the results-based management approach has played a significant role in enhancing the quality and timeliness of intervention implementation and overall planning.
The effective advocacy among religious leaders, along with the active participation of city political and health authorities in the implementation of the Tobacco-free City Initiative in Qom, has had a profound impact in protecting tobacco control legislation. In October 2019, a decision was made by the Islamic Consultative Assembly (Parliament) to exempt traditional restaurants and teahouses from national tobacco control laws, allowing smoking and the use of hookahs/waterpipes in these establishments. However, with the intervention of religious leaders, the efforts and support of parliamentarians, the Ministry of Health and Medical Education and WHO, the Guardian Council rejected this approval. The valuable intervention of the Expediency Discernment Council, in objecting to the legalization of tobacco supply in the country, further supported the Ministry of Health and Medical Education.
Given the significance of Qom as a holy city from political, cultural and religious perspectives, the successful implementation of this initiative can serve as a justification for expanding similar efforts to other religious cities in the region. Furthermore, the robust results-based management approach developed for the Tobacco-free City Initiative in Qom can serve as a foundation for the establishment of tobacco-free cities in countries within the Eastern Mediterranean Region and beyond.
Impact
Increased support from policymakers for tobacco control as a result of effective advocacy measures.
Engagement of relevant key authorities to provide support for the implementation of the initiative.
Establishment of a comprehensive surveillance, monitoring and evaluation system to oversee the Tobacco-free City Initiative.
Next steps
In the Qom Tobacco-free City Initiative, the goal is for Qom to be certified as a tobacco-free city by the end of 2020. The Ministry of Health and Medical Education and WHO have plans to expand the establishment of tobacco-free cities and villages across the country.
References
MPOWER measures to reduce demand for tobacco
STEPS country data and reports
WHO Framework Convention on Tobacco Control
Story originated in 2019.