MPOWER, needs and challenges: trends in the implementation of the WHO FCTC in the Eastern Mediterranean Region

Background: WHO MPOWER aims to help countries prioritize tobacco control measures in line with the WHO Framework Convention on Tobacco Control. Objectives: This paper assessed the progress and challenges in implementing the 6 priority policies of MPOWER in countries of the WHO Eastern Mediterranean Region since 2011. Methods: A checklist was developed and scores assigned based on the MPOWER indicators [maximum score 37]. MPOWER data for the Region in the 2015 and 2017 tobacco control reports were extracted and scored. Data from similar analyses for 2011 and 2013 were also included. Countries were ranked by scores for each indicator for 2015 and 2017 and for overall scores for 2011 to 2017. Results: The Islamic Republic of Iran, Egypt and Pakistan had the highest scores in 2015 [33, 29 and 27 respectively] and the Islamic Republic of Iran, Pakistan and Yemen had the highest scores in 2017 [34, 31 and 27 respectively]. The indicators with the highest and lowest combined score for all countries were for advertising bans and compliance with smoke-free policies: 67 and 18 respectively in 2015, and 73 and 15 respectively in 2017. Most countries [15/22] had higher total scores in 2017 than 2015: Afghanistan, Bahrain and Syrian Arab Republic had the greatest increases. The total score for the Region increased from 416 out of a maximum score of 814 in 2011 to 471 in 2017. Conclusions: Although notable achievements have been made in the Region, many challenges to policy implementation remain and require urgent action by governments of the countries of the Region

Third study on WHO MPOWER tobacco control scores in eastern mediterranean countries 2011-2015

This study was conducted to quantify the implementation of the MPOWER policies and to assess any possible changes across Eastern Mediterranean Region [EMR] countries. In this comparative cross-sectional study based on 10 categories mentioned in MPOWER report 2015 a checklist was designed. Seven questions were scored from 0-4 and three from 0-3. The 22 EMR countries were ranked and compared by their total score on a scale of 0-37. The highest scores were achieved by Egypt and the Islamic Republic of Iran. Pakistan, Sudan and Yemen showed progress, while Bahrain, Jordan, Kuwait, Oman, and the Syrian Arab Republic had decreased scores. The total score of the EMR countries had decreased compared to 2013. Thus, there remains a need for greater focus on tobacco taxation and smoke-free policies to address this retrograde step

Sanctions, smuggling, and the cigarette: the granting of Iran OFAC licenses to big tobacco

This paper seeks to understand the politician economy implications of nicotine addiction in Iran, focusing on the US office of foreign asset control's [OFAC] awarding of Iran operations licenses to American tobacco companies. Presuming that tobacco taxes, levied both as import duties and ad valorem, would financially benefit the Iranian Government, such the introduction of a highly desired US product to the market would be antithetical to the sanctions regime currently in place. By comparing Iran's tobacco industry and the attendant public health crisis that has arisen from high rates of nicotine addiction, to conditions in Turkey, it can be demonstrated that Iran is uniquely unable to extract revenues from the sale of tobacco products. The primary point of comparison between Iran and Turkey is smoking-attributable annual productivity loses of each country as estimated through the use of smoking-attributable mortality, morbidity and economic costs software [SAMMEC] and the available related literature. Based on the calculations derived from the SAMMEC model, Iran is burdened with an incredible cost to the economy borne by a high prevalence of smokers. It is concluded that an awareness of this condition enables OFAC to award licenses to big tobacco without fear of undermining current foreign policy initiatives

Iranian audience poll on smoking scenes in Persian movies in 2011

Scenes depicting smoking are among the causes of smoking initiation in youth. The present study was the first in Iran to collect some primary information regarding the presence of smoking scenes in movies and propagation of tobacco use. This cross-sectional study was conducted by polling audience about smoking scenes in Persian movies on theaters in 2011. Data were collected using a questionnaire. A total of 2000 subjects were selected for questioning. The questioning for all movies was carried out 2 weeks after the movie premiered at 4 different times including twice during the week and twice at weekends. A total of 39 movies were selected for further assessment. In general, 2,129 viewers participated in the study. General opinion of 676 subjects [31.8%] was that these movies can lead to initiation or continuation of smoking in viewers. Women significantly thought that these movies can lead to initiation of smoking [37.4% vs. 29%]. This belief was stronger among non-smokers as well [33.7% vs. 26%].Despite the prohibition of cigarette advertisements in the mass media and movies, we still witness scenes depicting smoking by the good or bad characters of the movies so more observation in this field is needed

comparative study on tobacco cessation a quantitative systematic review

During recent years, there have been many advances in different types of pharmacological and non-pharmacological tobacco control treatments. In this study, we aimed to identify the most effective smoking cessation methods used in quit based upon a review of the literature. We did a search of PubMed, limited to English publications from 2000 to 2012. Two trained reviewers independently assessed titles, abstracts and full texts of articles after a pilot inter-rater reliability assessment which was conducted by the author [GH]. The total number of papers and their conclusions including recommendation of that method [positive] or not supporting [negative] was computed for each method. The number of negative papers was subtracted from the number of positive ones for each method. In cases of inconsistency between the two reviewers, these were adjudicated by author. Of the 932 articles that were critically assessed, 780 studies supported quit smoking methods. In 90 studies, the methods were not supported or rejected and in 62 cases the methods were not supported. Nicotine replacement therapy [NRT], Champix and Zyban with 352, 117 and 71 studies respectively were the most supported methods and e-cigarettes and non-Nicotine medications with one case were the least supported methods. Finally, NRT with 39 and Champix and education with 36 scores were the most supported methods. Results of this review indicate that the scientific papers in the most recent decade recommend the use of NRT and Champix in combination with educational interventions. Additional research is needed to compare qualitative and quantitative studies for smoking cessation

Smoking and diet in healthy adults: a cross-sectional study in Tehran, Iran, 2010

Smoking and unhealthy diet are two major risk factors for non-communicable diseases. The aim of this study was to investigate the possible association between these two risk factors amongst healthy adults 30-60 years old in Tehran, Iran. Overall, 2602 healthy adults 30 to 60 years old in Tehran were studied. The demographic characteristics, anthropometric and smoking status of the participants were questioned. The frequency of consumption of red meat, white meat, fruits and vegetables, dairy products, bread and cereals and fast food were questioned to be daily, weekly, monthly, once every 6 months or yearly and categorized as "healthy" or "unhealthy". Of the 2602 participants, 974 [37.4%] had smoked more than 100 cigarettes in their life time and continued daily or smoked occasionally. Smokers significantly consumed more fast food and white meat but less fruit and vegetables and dairy product [P<0.0001]. Totally, 586 [22.5%] consumed "unhealthy" diet. A positive association between cigarette smoking and unhealthy diet [OR=1.68; 95% CI: 1.40-2.03] were found. After adjusting the analysis for the effect of age, education and gender, the odds ratio of consuming unhealthy diet for the smoker increased to 1.83 [1.50, 2.25] compared with non-smoker. Our study found a noticeable association between cigarette smoking and unhealthy diet. Smoking cessa-tion and changing diet program for smokers is recommended

Cigarette smoking, knowledge, attitude and prediction of smoking between male students, teachers and clergymen in Tehran, Iran, 2009

Students, clergymen and teachers as role models can be very important in encouragement or prevention of cigarette smoking in young people. The aim of this study was to compare prevalence of smoking in 3 male groups of teachers, clergymen and university students. Also, study their knowledge and attitude towards it and the prediction of their future consumption. In a cross sectional study in 2009 in Tehran, Iran, 1,271 male students, 549 clergymen and 551 teachers were randomly enrolled. Each participant completed the global adult tobacco survey questionnaire. Knowledge, attitude and prediction of smoking for the next 5 years were questioned in these 3 groups. Chi-squared test and logistic regression were used for analysis. P < 0.05 was considered significant. Prevalence of cigarette smoking was 31.1%, 21.9% and 27.2% among students, clergymen and teachers, respectively. Smoking in students was not associated with poor knowledge but were in teachers and clergymen. The odds ratio of smoking in students, clergymen and teachers was higher among those with having inappropriate attitude towards it [OR = 1.6, 6.1 and 4.5]. Those with poor knowledge had an inappropriate attitude and predicted higher chance of cigarette consumption in the next 5 years [P < 0.0001]. Inappropriate attitude in all 3 groups resulted in higher prediction of future smoking [P = 0.008]. This study revealed that the prevalence of smoking among male students and teachers was higher than general population and clergymen who equally smoked. Also, level of knowledge and attitude of students were lower than teachers and clergymen

Comparison of spermatozoa quality in male smokers and nonsmokers of Iranian infertile couples

Smoking has a negative effect on fertility and sperm quality. This study was designed to evaluate the effects of smoking on sperm quality and the related parameters such as sperm concentration, morphology and motility. This cross-sectional study was conducted on 180 infertile men with at least one year history of idiopathic infertility, who admitted to the Avicenna Infertility Center, Tehran, Iran. A complete history including smoking habits and other diseases was obtained and semen analysis was performed for all participants. Statistical analysis was performed using SPSS software version 16 and t test and Mann-whitney tests with a significance level of alpha = 0.05. Comparison of sperm parameters in the two groups of smoker and nonsmoker subjects showed that active smoking [p=0.04] and cigarette consumption even in small amounts [p=0.03] decreased sperm concentration, However, no significant correlation was detected between smoking status and morphology or motility of sperms. This study failed to find a significant correlation between sperm analysis and smoking status except for sperm concentration, which was significantly decreased in the active smokers ,even in those consuming small amounts of tobacco. This finding propounds that tobacco consumption may negatively affect fertility

Efficacy of telephone quit-line for smokers in Iran: 12 months follow up results

Smoking cessation is an effective intervention for cancer prevention. For some reasons many smokers cannot attend quit programs and they prefer to have a consultation over the phone. In this study we share our experience regarding setting up a quit-line for smoking cessation for the first time in Iran. Two general practitioners were trained to give consultation over the phone via quit line in Tehran. The quit program consisted of 4 sessions with 1 week interval. Our telephone counseling was both reactive and proactive from 8 AM till 5 PM during the years 2005 - 2008. In reactive counseling, the smoker initiates the call and speaks with a counselor about his/her current concerns. In proactive counseling, the counselor calls the smoker and provides counseling in a systematic manner. Smoking status was determined based on smokers' self-report and regular follow-ups were conducted after quitting. Some cases were randomly selected for CO respiratory test in order to confirm their abstinence. A total of 480 cases entered the cessation program out of which, 80% were males. The mean age was 38.5 +/- 7.9 years, 72.7% of participants were married, 75.2% of subjects were educated and 51.3% of cases had high nicotine dependence. A total of 332 cases received a brief advice on quitting, 148 people continued their active participation to complete the course and 122 cases [82.4%] quitted smoking. The sustained abstinence rate after 1, 3, 6 and 12 months was 59%, 41%, 31% and 18%; respectively. This method is an appropriate and accessible method which can be suggested to smokers during smoking cessation counseling

[Evaluation of the smoking habit among male students of all faculties of the Shahid Beheshti University and Shahid Beheshti Medical Science University during 2008]

Cigarette smoking and consuming other tobacco products are the behaviors that generally start in adolescence. This study was done to evaluate the prevalence of smoking in male students of Shahid Beheshti University in 2008. This is a questionnaire-based cross-sectional study. The questionnaires were designed in accordance with the WHO and IUATLD questionnaires; validity and reliability of questionnaires were assessed in previous samples. Smoking prevalence and its determinants were evaluated using SPSS software. 1271 students including 765 [60.2%] medical students and 506 [39.8%] non-medical students were included in the study. In this population, 782 [61.5%] students had had smoking experience, among which 395 [31.1% of whole population and 50.5% of experienced smokers] smoked 100 cigarettes or the same amount of nicotine from other tobacco products. This figure increased significantly with an increase in the number of terms the students had attended the university i.e. senior students, [p=0.000]. There was no significant difference between smoking 100 cigarettes in medical and non-medical students, [p=0.08]. Figures for smoking experience and smoking 100 cigarettes were respectively 63.7% and 54.2% among medical students and they were 58.3% and 44.4% among non-medical students. Considering the high rate of smoking experience in this population, it is essential to implement prevention programs before entrance to the universities and the increasing rate of smoking in senior years calls for educational interventions in universities

[Evaluation of knowledge, attitude and practice about smoking among male teachers in Tehran, Iran]

To assess knowledge, attitude and practice about smoking should be evaluated as their cigarette smoking may lead to smoking among teachers in Tehran, Iran. This was a cross sectional study carried out in Tehran, Iran. A random sample of teachers from 50 schools were selected. Data on knowledge, attitude and practice about smoking were recorded using a WHO based questionnaire. In all 551 male teachers were took part in the study. 150 teachers reported that they smoke more then 100 cigarettes of these 80 teachers [14.5%] reported to smoke daily, 40 teachers [7.3%] smoked occasionally and 30 teachers [4.5%] have quit smoking. So their cigarette smoking prevalence was stimated to be 27.2% [CI 95%:23.5%-31.1%]. The prevalence of smoking among teachers was not different in different educational districts [P=0.13]. Also, there was no statistical difference between the prevalence of smoker born in Tehran and elsewhere [P=0.18]. In addition, type of employment and smoking status were not associated [P=0.25]. However, the association between knowledge, attitude and practice and smoking status of teachers were found statistically significant [P<0.0001]. Since, smoking habits among teachers was similar to general population and because the students imitate their teachers, therefore, educational tobacco control programs for teachers should be designed and implemented in order to reduce tobacco smoking in this group and finally among the students

[Does smoking cessation result depend on smoking reason?]

Since the smoking reason for different smokers needs different treatment methods and special advices, it is necessary to specify these reasons. This study designed to know the main smoking causes in Iran, in order to design proper treatment methods and behavioral therapies for smoking cessation. In addition the study thought to evaluate the effects of these reasons on the quit results and the probable circumstances of these effects. This was a cross-sectional study carried out in Tehran, Iran. All people attending to smoking cessation clinics [affillated to Research Institute for Tuberclosis and Lung Diseases, Shahid Beheshti University of Medical Sciences] were invited to take part in the study in year 2006-2008. Volunteers answered 13 items of the Iranian version of the Modified Reasons for Smoking Scale [MRSS], Fagerstrom test and demographic characteristics. All participants have been assessed by a physician and they participated in a four-session per week program including nicotine replacement and non-nicotinic therapies and behavioral therapy. All participants were followed-up for 6 and 12 months after quiting smoking. In all 822 participants including 590 men [68.7%] with mean age of 43.8 +/- 13.2 years were studied. All analyses were adjusted for sex and Fagerstrom test score. Pleasure to smoke was found as the principle reason for failure to smoking cessation in the end of clinical trial [P=0.004]. In 6 and 12 months follow-up, failed quitting was predicted by pleasure to smoke and hand-mouth activity score [P<0.05]. The study findings suggest that reason for smoking is associated with its quiting

Efficacy of nicotine patch in combination with trazodone in smoking cessation

Treatment for tobacco dependency involves a combination of behavioral therapy, antidepressants, and nicotine replacement therapy. This study was conducted in order to compare the outcome of smoking cessation by using each of the four forms of nicotine replacement therapy [NRT] among participants using Trazodone tablet 50 mg. In this non-randomized quasi-experimental study the efficacy of four mentioned forms of nicotine replacement therapy [NRT] including patches, gums and microtabs and two forms of NRT together was evaluated. Smoking cessation while using Trazodone was also studied. All the smokers who referred to the smoking cessation clinic of Iranian National Research Institute of Tuberculosis and Lung Diseases [NRITLD], Tehran, Iran from Oct. 2005 to Oct. 2007 entered the study. They attended 4 weekly sessions followed by 2 sessions in the next 12 months. A total of 286 subjects participated in this study. Trazodone was prescribed for them and 253 used at least one form of NRT. There were 181 [74.6%] males. The mean age was 42.43 +/- 13.4 yrs. Thirty three cases selected nicotine patches, 99[39.4%] used nicotine gums, 64[25%] chose microtabs and 57[23%] preferred using two types of NRT simultaneously. A total of 152 participants [60%] quit smoking at the fourth session. At the fourth session, it was proved that nicotine patches had the highest success rate and were most efficient for quitting smoking [94%]. Also, after 6 and 12 months follow-up it was found that nicotine patches were most effective for abstinence. Nicotine patches used in combination with Trazodone tablets could result in higher success rates for smoking cessation

What kind of cigarettes do smokers use in Tehran?

Smoking is the first preventable cause of death in the world. Regulating the production, import, distribution and sell of cigarettes is the most prominent action for implementation of tobacco control programs. In this regard, it is necessary to know the smoker's choice in terms of different cigarette brands. This study has been designed before the implementation of Framework Convention of Tobacco Control [FCTC] and Iranian Comprehensive Tobacco Control Law. This cross-sectional study was conducted through questioning during the year 2006. Health-care personnel were chosen for conduction of this project and participated in training courses conducted with the cooperation of Health Departments of 3 major universities in Tehran. The Questionnaires were designed according to WHO and IUATLD questionnaires. Health-care workers distributed the questionnaires among smokers in specific areas. A total of 3026 people participated in this study among which 2413 [79.7%] were men. Consumption of foreign-made cigarettes was 65.5% whereas consumption of locally-made cigarettes was 34.5%. Also, the use of legally-imported cigarettes was 55.9% compared to the use of illegally-imported cigarettes which was 44.1%. Consumption of foreign-made and illegally-imported cigarettes was higher among women [78.4% and 72.5%, respectively]. Also, consumption of foreign-made cigarettes among the age group of under 25 years old was less than any other age group [52%]. Consumption of foreign-made and illegally-imported cigarettes was considerably high in our population and even higher among women. Therefore, it is recommended that the authorities make it hard for the people to access illegally-imported and smuggled cigarettes by complete implementation of tobacco control programs and by adopting effective anti-smuggling measures

Efficacy of different methods in decreasing the students' tendency towards smoking

Smoking is the first cause of preventable morbidity and mortality in the world. This study aimed to compare different methods in reducing the students' tendency towards smoking. This semi-experimental study comprised all 7th grade students studying in middle schools throughout Iran in the year 2005-2006. Students were divided into 4 groups three study groups [social skills training, increasing knowledge and poster presentation] and 1 control group. Sampling method used was multi-phase cluster. The country was geographically divided into 5 districts [north, south, east, west and central] and the provinces were selected randomly. A questionnaire was used to collect the data. These questionnaires were designed to evaluate the attitude and knowledge of students with regard to smoking and complications. A total of 2911 students with the mean age of 13 years were studied out of which 7.4% were smokers. There were significant differences between the study groups and the control group regarding the attitude and knowledge about the hazards of smoking and abuse of illicit substances. In other words, among the study groups, social skills training, building knowledge and poster presentation had the best results, respectively. In evaluating the preventive methods, social skills training group had the most negative attitude and the highest level of knowledge concerning the disadvantages and hazards of smoking and use of illegal substances. The greatest decrease in smoking was also observed in this group. Social skills training can be an effective preventive measure to control smoking by emphasizing self-respect, problem-solving skills and self restraint

Evaluation of age and smoking habit by verbal autopsy

Cigarette smoking is the first preventable cause of morbidity and mortality in the world and can result in various diseases, disability and death. International studies have reported that about half of the smoking-related deaths occur in the middle ages. We decided to assess the age of death among smokers and non-smokers in this study. This descriptive cross-sectional study was conducted at Tehran Behesht-e-Zahra Cemetery between September 2005 and March 2006. To estimate the sample size, a pilot study was performed on 112 deaths in March 2005 and based on the results; the sample size was estimated to be 2500. Five days of each month were selected randomly. On these days a physician [co-author] visited the Cemetery office and collected the data with the help of office operator. Information was obtained from first-degree relatives of the deceased after obtaining consent. The under-study variables were age at the time of death and cigarette use. Data were analyzed by SPSS software version 11 and using ANOVA test. A total of 7858 cases were studied out of which 57.3% were males. There were 63.1% [4960] non-smokers, 25.1% [1971] smokers and 11.8% [927] ex-smokers. The mean age of death among total under-study population was 56.8 yrs [55.1 yrs in males and 57.6 yrs in females]. The mean age of death was 57.9 yrs among non-smokers, 50.1 yrs among smokers and 56.8 yrs among ex-smokers [p=0.00]. Results showed that age of death was lower among smokers but we could not determine a direct correlation between cigarette smoking and death in these patients