What is waterpipe?

Waterpipe has different names in different countries such as narghileh, shisha, hookah, hubble-bubble, or goza.

The World Health Organization (WHO) defines waterpipe tobacco smoking (WTS) as “a form of tobacco consumption that utilizes a single or multi-stemmed instrument to smoke flavoured or non-flavoured tobacco, where smoke is designed to pass through water or other liquid before reaching the smoker”.¹ Some countries have developed their own definition of waterpipe tobacco smoking (WTS).²

The origin of WTS is somewhat unclear. In the late 19th century, it was popular among older men in the Middle East but with the introduction of sweetened and flavoured tobacco in the early 1990’s, waterpipe use surged among youth, and expanded globally, through universities and schools.³⁴

Social acceptability of waterpipe use has increased, due to the growth of ‘café culture’ in the Middle East and globally, becoming the focus of social gatherings of young people, as a waterpipe can be shared by a group of friends over an extended time, with a slow puff rate. Tourists have taken the waterpipe habit back to their countries, and expatriates from the Middle East have opened waterpipe cafés and restaurants around the world.¹⁴⁵⁶In this way waterpipe has spread beyond the Middle East and become integrated into the global tobacco market.⁷ While there are restrictions on tobacco advertising in other regions, products have been promoted throughout the Middle East via satellite television, internet and social media. As these media are largely unregulated the industry is able to circumvent most advertising bans (see below for more on product regulation).⁵⁶¹

Transnational tobacco company interests

Historically, transnational tobacco companies had little interest in waterpipe tobacco smoking. A review of tobacco industry documents showed no focus on waterpipe tobacco or its accessories, except for some ‘waterpipe-inspired’ products that did not become mainstream in the market.⁸

This was the case until  2012, when Japan Tobacco International (JTI) acquired Egyptian company Al Nakhla.⁹ At the time Al Nakhla was globally the largest company manufacturing waterpipe tobacco products.¹⁰ However, even this was perceived as a strategy to enhance the sale of cigarettes.⁸

In 2019, Philip Morris International (PMI) filed a patent ‘Shisha device for heating a substrate without combustion.’⁸  However, as of 2023, this product had not yet appeared on the market.

• See Waterpipe market below for details on companies, brands and market shares

Use

Image 1: Waterpipe device (Source: Waterpipe Briefing, National Centre for Smoking Cessation and Training/Jawad et al 2013)¹¹¹²

Waterpipe tobacco is smoked using a device like that in image 1. As the smoker draws from the mouthpiece, a piece of lit charcoal heats the waterpipe tobacco leaf within the head of the apparatus. This heat generates smoke that travels through the device’s body and enters the water-filled bowl. By inhaling through the hose attached to the top of the bowl, the smoker pulls the smoke through the water, resulting in bubbles, before finally inhaling the smoke via the mouthpiece. Typically, the head is filled with flavoured and sweetened, and it is separated from the charcoal by a perforated aluminium foil. While the specific design and characteristics may vary across different regions, the fundamental principle remains consistent: the smoke is filtered through water.⁵

E-hookahs or e-shisha or hookah pens are not waterpipe devices as they do not involve burning charcoal. These are classified as electronic nicotine devices, similar to e-cigarettes, where a sweetened liquid is electrically heated creating an aerosol to be inhaled.¹

• For more information on e-cigarettes and other product types see Tobacco Industry Product Terminology

The role of flavour

The traditional type of waterpipe tobacco smoking (WTS) uses unflavoured types of leaf (Ajami, Tumbak, or Jurak). However, since the 1990s flavoured tobacco has become more popular.⁵⁶¹

The most common type is Maasel (or Mo’assel), or ‘honeyed’ tobacco, which consists of one-third tobacco and two-thirds honey and fruit flavours, usually a combination of tobacco, molasses, glycerine and fruit flavours.¹³. A review looking at waterpipe use in the USA, Canada and the UK has shown that young adults use waterpipe mainly for its appealing flavours, always preferring it over other tobacco products.¹⁴  A study among , adults in Lebanon indicated that the introduction of novel tobacco flavours contributed to people initiating WTS and increased its use.¹⁵ Similarly, a study from Iran indicated that the wide variety of flavours has as well contributors to the increase in prevalence of smoking among youth and women. The different flavours were considered ‘tempting’.¹⁶

• For information on the appeal of flavoured tobacco products see Flavoured and Menthol Tobacco

Health effects

Evidence shows that waterpipe, like other tobacco and nicotine products, is addictive.¹⁷

As with cigarettes and rolling tobacco the smoke of waterpipe is toxic and carcinogenic. One study identified 27 known or suspected carcinogens. ¹⁸As a waterpipe is often shared, it is also a mode of transmission for communicable diseases, a particular concern during the COVID-19 pandemic.¹⁹ Consequently, waterpipe has both  short-term and long-term harmful health impacts on people who use it, and additional harms for those exposed to second-hand smoke.^1202122

Among many groups of users there is a belief that the smoke of waterpipe is filtered in water, making it less harmful than cigarette smoking. This perception has contributed to a growing popularity and acceptance.⁵⁶¹ For example research from the UK found that:

“[w]aterpipe was perceived to be safer than cigarette smoking due to the pleasant odour, fruity flavours, and belief that water filtered the toxins.”²³

However, waterpipe contains similar or greater levels of toxic substances, leading to the same cellular effects as conventional products, leading to pulmonary and arterial diseases.¹⁸²⁴

Prevalence

A 2018 systematic review, which included 129 studies from 68 countries, found that use of waterpipe was highest among adults in the Eastern Mediterranean region (EMR). However, among youth, prevalence was similar in Europe and EMR. Comparing WTS between adults and youth, globally the study reveals that smoking is higher among youth.²⁵

A WHO advisory note about waterpipe, published in 2015, indicated that although waterpipe smoking was traditionally associated with the Eastern Mediterranean region, Southeast Asia and Northern Africa, its use is growing globally among youth and adults of both genders. Use is particularly increasing among schoolchildren and university students. Research reported in the WHO advisory note ⁶ and a study from Lebanon indicates that the shape, colour and size of the apparatus contributed to the popularity of WTS product mainly among women.²⁶

Africa

Research in South Africa from 2012, shows that 20% of poor high-school students reported using waterpipe daily, and 60% reported ever having used one.²⁷ A study in Western Cape from 2013, reported higher figures: 40% current use, and 70% ever use.²⁸ Even among medical students, use may be relatively high; a study in Pretoria in 2010 found that nearly 20% of participants had used a waterpipe at some time.²⁹

The Americas

Although there is limited research on waterpipe in Latin America, some has been conducted in the United States (US) and Canada. In US a national study of 104,434 university students, published in 2014, shows that after cigarette smoking, waterpipe smoking was the most frequent form of tobacco use (8.4%, compared to 29.7% for cigarettes), and over 30% reported using waterpipe at some time.³⁰ In Canada, although cigarette smoking among young people had significantly decreased, waterpipe use increased by 2.6% among young people between 2006 and 2010.³¹

Eastern Mediterranean

This region has the highest prevalence of waterpipe use. Studies (1999 – 2008) suggest that waterpipe use was more frequent than cigarette smoking among children aged 13–15 in most countries of the region.³² It also increased in multiple countries, with prevalence ranging from 9% to 15%.³³

Europe

Evidence compiled in 2012 showed that, among people aged 15 years or over, 16% had tried waterpipe at least once. Studies suggest waterpipe prevalence ranging from 35-40% in Latvia, Estonia, and Lithuania, but below 10% in Malta, Spain, Portugal, and Ireland. Use was growing sharply in Austria, the Czech Republic and Luxembourg.³⁴ In England, data from 2013 indicated that for people aged 16-18 the level of waterpipe smoking was low, at 3%.³⁵

However, a study looking at adult smoking in England using a nationally representative cross-sectional survey found that since then pipe, cigar or waterpipe smoking increased five times – from around 150, 000in 2013 to over 770, 000 in 2023. Cigars was the most used of the three product types, closely followed by waterpipe, and the increase was higher among young adults.³⁶.

South-East Asia

Studies (2008 – 2011) suggest that waterpipe prevalence among men was just over 1% in Bangladesh, and in India, and much lower in in Indonesia and in Thailand (0.3%). Fewer than 1% of women use waterpipe in India Bangladesh,  Indonesia, and Thailand.³⁷³⁸ However, waterpipe “hookah” bars and restaurants are becoming increasingly common and are most often frequented by young people.

Western Pacific

Waterpipe is called “bong” and is different in design from the popular Middle Eastern waterpipe, and therefore is often not included in waterpipe studies. It can be made of bamboo, metal or glass and is used in China, the Lao People’s Democratic Republic, Myanmar, and Vietnam. In 2010 in Vietnam around 13% of males aged or over 15 used bong.³⁷

Regulation

In many higher income countries, waterpipe products are exempted from tobacco control policies. In many lower income countries, even if there is a policy, enforcement is very weak. Although flavouring is a major factor in the appeal to young people, flavour bans often do not cover waterpipe tobacco products. Consequently, the use of waterpipe has increased globally, largely unchecked.⁵⁶¹⁴

The WHO Framework Convention on Tobacco Control (WHO FCTC) identifies tobacco products as “products entirely or partly made of the leaf tobacco as raw material which are manufactured to be used for smoking, sucking, chewing or snuffing”.³⁹ This definition covers waterpipe tobacco products. WHO FCTC issued COP decisions specifically for waterpipe tobacco control:

• At COP3 in 2008, Parties were invited to consider introducing health warnings and messages on tobacco packages, including waterpipe, and to use innovative measures requiring health warnings and messages to be printed on instruments used for waterpipe smoking.⁴⁰
• At COP6 in 2014, Parties were invited to strengthen the implementation of WHO FCTC on waterpipe, including conducting surveillance of its use and research on its market. This decision also invited the Secretariat of the Convention to work with the WHO to support countries in waterpipe control.⁴¹
• At COP7 in 2016, more detailed instructions were given to Parties, including to ban the use of flavourings in waterpipe tobacco products.⁴²
• At COP8 in 2018, there is a decision on the implementation of Articles 9 and 10 of the WHO FCTC (Regulation of contents and disclosure of tobacco products, including waterpipe, smokeless tobacco and heated tobacco products), including the establishment of an expert group to examine the reasons for low implementation of Articles 9 and 10 of the Convention.⁴³

The full list of articles covering waterpipe are listed in the Fact sheet: Waterpipe tobacco smoking & health.¹

In January 2016, the Secretariat of the WHO FCTC signed a Memorandum of Understanding with The American University of Beirut making it the global knowledge hub for WTS, in particular with respect to education, research, and the dissemination of information that contributes to the implementation of the Convention. ⁴⁴

In 2018, the WTS knowledge hub submitted a report to the WHO FCTC COP8 that summarized Parties’ regulations concerning waterpipe.⁴⁵ This report was updated in 2022, and found that, of the 90 countries reviewed, over half (47) had policies relating to waterpipe.² The majority of policies, nearly 45%, were in Europe and around 21% in EMR.²

For up-to-date information on tobacco regulation, see the Tobacco Control Laws website, published by the Campaign for Tobacco Free Kids (CTFK).
Information on progress by parties can be found in the FCTC Implementation database.

During the COVID-19 pandemic in 2020, many countries temporarily banned the use of waterpipe as part of their efforts to stop the spread of the infection.¹⁹ In EMR alone, 17 countries banned waterpipe tobacco use in public places.⁴⁶

Waterpipe, along with heated tobacco products, had been exempted from the EU flavour ban, stipulated by the 2014 European Tobacco Products Directive (TPD) and implemented in 2020. A new directive was issued in 2022 and came into force in 2023. This removed the exemption, bringing regulation of these products in line with cigarettes and hand rolled tobacco.⁴⁷⁴⁸ This means that waterpipe tobacco with a “characterising flavour” can no longer be sold legally in the EU. For more information see Menthol Cigarettes: Industry Interference in the EU and UK.

Waterpipe market

According to advocacy group It’s Still Tobacco, the region with the largest global market share of WTS is the Middle East and Africa (MENA), a range estimate for the two years2016-2017 to be 54% to 69% in.⁴⁹

The WTS market is still concentrated in the Middle East and Africa, followed by  Europe.⁵⁰ Market analysis company Valuates estimated that as of 2022 the global WTS market was worth over US$ 800 million, forecast to nearly double by 2029.⁵⁰

Market research company Euromonitor International publishes data on waterpipe, as part of the broader pipe tobacco category. It is therefore hard to estimate global market shares specifically for waterpipe tobacco. However, it is possible to identify specific waterpipe brands in the data. In 2022, JTI held the largest share with Al Nakhla, making up nearly 13% of the entire pipe tobacco market, followed by Al Fakher and Eastern brands (including Moassel) at around 12% and 8% respectively.⁵¹

Tobacco industry interference

The waterpipe industry is multidimensional, composed of both tobacco and non-tobacco actors, including third parties. Interference can therefore be less obvious, making it difficult to develop effective WTS policy.⁵² However, there is some evidence of the tactics used by the industry and its allies.

Tobacco industry tactics used to interfere with and undermine regulation relating to waterpipe include:

Use of third parties

The third-party technique includes creating, funding and empowering allies and front groups.

The public representation of the WT industry primarily revolves around the hospitality sector (waterpipe cafes, bars, and restaurants).⁴⁹ Products are promoted online by users via social media, rather than WT companies.⁴⁹  A study from Lebanon indicates that, following the passage of the tobacco control law, enforcement of a ban on indoor smoking came to a halt due to the lobbying of policy makers by establishments where waterpipe was available.⁵³

In 2012, the hospitality sector in Lebanon commissioned Ernst & Young (now EY) to evaluate the effects of the smoke-free law on their financial revenue and impact on employment.⁴⁹⁵⁴

Spreading misleading information

Waterpipe companies have published misleading information, including on the risks of tobacco products.

A study of 16 company websites indicated that most (n=12) published misleading marketing information This was mostly prominent among non-MENA companies (n=8) compared to MENA companies’ websites (n=4).   Several companies in Jordan (Al-Rayan, Al-Tawareg, Al-Waha, and Mazaya) were found to have disseminated misleading information on the quality and safety of WTS.⁴⁹  WTS charcoal companies in particular published misleading information about charcoal being ‘100% natural’ and ‘free of chemicals’.⁴⁹

Another study looking at marketing materials at a European trade fair,  and from the MENA region, found the prevailing message was that waterpipe is less risky compared to cigarettes.⁵⁵

Industry science

Al Fakher Tobacco Trading LLC, the second largest WT company, has a ‘shisha science’ section on its website and publishes its own research. A poster of a study published on its page indicates that the paper was presented at the CORESTA Smoke Technology Conference, in 2019. The study argues that a comparisons of Total Particulate Matter (TPM) yields between waterpipe and cigarettes do not provide meaningful information to inform an assessment of relative risk of its products.⁵⁶

For information on science websites of transnational tobacco companies, see:

• Industry Approaches to Science on Newer Products

Illicit trade

Although cigarettes form most of the illicit tobacco trade, there is some evidence of illicit trade relating to waterpipe, specifically in the Eastern Mediterranean and South-East Asian regions.⁴⁹¹.

Research from Turkey indicates that the majority (up to 99%) of waterpipe tobacco is illicitly traded, reflecting the significance of the informal economy in the waterpipe tobacco market.⁵⁷ The illicit products are from both unauthorized domestic production, and increasingly tobacco smuggled from other countries, reported to taste better than locally manufactured products.⁵⁸

OLAF, the European anti-fraud office, has identified suspicious shipments of waterpipe tobacco heading into Europe. In 2022, OLAF detected a truck carrying 20,000 kg of waterpipe tobacco as it was leaving Türkiye on its way to Denmark.⁵⁹

Tax evasion

There have been some documented cases of the under reporting of imports and exports of waterpipe tobacco, in order to evade tax.

In 2022, New Zealand changed its taxation law related to WTS to base it on product weight rather than the content declared by importers, as the customs authority suspected that some importers had been under-declaring tobacco content in order to avoid paying tax. ⁶⁰

In 2023, the Mozambique the tax authority seized two containers of waterpipe tobacco, reporting the lack of a proper declaration for taxes and other customs fees.⁶¹

Relevant Links

• WHO FCTC Knowledge Hub for Waterpipe Tobacco Smoking
• Virginia Commonwealth University Center for the Study of Tobacco Products video Addressing the Myths of Hookah

TobaccoTactics Resources

• Eastern Mediterranean Region
• Industry product terminology
• Japan Tobacco International

TCRG Research

Waterpipe tobacco smoking (WTS) control policies: global analysis of available legislation and equity considerations,  H. Alaouie, R.S. Krishnamurthy, M. Tleis, L. El Kadi, R.A. Afifi, R. Nakkash, Tobacco Control, 2022, 31(2):187-197. doi: 10.1136/tobaccocontrol-2021-056550

References

The post Waterpipe appeared first on TobaccoTactics.

This is one of six geographic regions of the World Health Organization (WHO). This region includes 22 countries, with a total population of nearly 679 million people.⁶²

Smoking in the Eastern Mediterranean Region

The latest WHO tobacco trends report, 2019, projects a smoking rate (properly called tobacco prevalence) of 18.6% in the EMR in 2020. The report expects a tobacco prevalence decrease in the region from the estimated 20.5% in 2015 to 17% in 2025. This decrease will however mean an increase in numbers of tobacco users from the estimated 90 million in 2015 to 94 million in 2025 because of population growth.⁶³

The report also shows a huge difference in tobacco prevalence according to gender with 33.3% tobacco prevalence among males but just 3.9% among females. Another remarkable difference is the tobacco prevalence across different countries in the region. It starts at 9.6% in Oman and reaches 42.6% in Lebanon.⁶³
The EMR has the highest waterpipe use as compared to any other region. Waterpipes are a particular method of consuming tobacco with it heated and drawn through water in inhaled via a pipe., It is estimated that schoolchildren aged 13–15 use waterpipes more frequently than cigarettes.⁶⁴ Studies indicate mean prevalence estimate of ever use of waterpipe of 31.9% among adults in the EMR.⁶⁵

Tobacco in the Eastern Mediterranean Region

Out of the 22 countries of this region, at least 14 countries grow tobacco and at least seven countries manufacture it. The following table shows a summary of agriculture and production of tobacco in the EMR (table 1). This table is based on fact sheets prepared jointly by WHO and the United Nations Conference on Trade and Development in 2015. However it is believed that both agriculture and production are much higher now.⁶⁶

Table on agriculture and production of tobacco in the EMR

Who dominates the market?

The tobacco products that destroy so many people’s lives are the result of the activities of a number of companies around the world. The Tobacco Supply Chain Database enables tobacco control researchers and advocates to understand what the supply chain is, where it is located and who is involved. For more information, access the database here.

The cigarette market in the EMRO region is dominated by international and multinational companies, with their brands being the most sold cigarette in at least 12 countries. Locally produced cigarette brands are still the highest sellers in at least four countries. The waterpipe market shows a growing presence from multinational companies.⁶⁷⁶⁸

Table showing countries with most sold cigarette brand owned by international and multinational companies

Table showing the countries with most sold cigarette brand owned by local companies

Table giving examples of the dominant brands of waterpipe in the region

Links to governments

The industry aims to make sure it is well-represented

The industry has an established strategy in the region to lobby political figures and governments to serve its benefits. This strategy indicates links between tobacco industry and senior officials in the region trying to influence their decision making process.⁸⁰
It is reported that the tobacco industry used corporate social responsibility activities as a strategy to access officials in Egypt, Jordan, Lebanon, Morocco, Pakistan, Tunisia and the United Arab Emirates. An example of the industry lobbying in the EMR is in trying to influence the countries’ selection of their representatives to the Conference of Parties (COP) of the WHO Framework Convention on Tobacco Control (WHO FCTC). Tobacco industries have pushed countries to send representatives from non-health sectors, who may see tobacco as a business rather than a health hazard.⁸¹

There are state-owned and state-supported companies in number of EMR countries such as the Eastern Company in Egypt, Iran Tobacco Company in Iran, National Tobacco and Matches Corporation in Tunisia, Regie Libanaise des Tabacs et Tombacs in Lebanon, Régie des Tabacs in Morocco, and Kamaran Industry and Investment in Yemen. Most of these companies are a monopoly in charge of production, importing, and exporting tobacco products.⁸²

Examples of good practice

Iran, one of the leading tobacco control countries in the region, is reported to be a successful country in resisting tobacco industry interferences by adherence to the WHO FCTC Article 5.3 guidelines. Iran bans corporate social responsibility activities by the tobacco industry and does not accept any support from or presence of the representatives of the Iranian Tobacco Company, a state monopoly, in its tobacco control policy making process.⁸³

Saudi Arabia, another leading tobacco control country in the region, has issued a policy to regulate communication and interaction, if required, between the government officials and tobacco industry. The policy reflects the principles and recommendations of Article 5.3 of the WHO FCTC. ⁸⁴

Roadmap to tobacco control

Most countries of the EMR are parties to WHO FCTC with 19 out of 22 countries have ratified joining the treaty.⁸⁵ Additionally, six countries of the region are parties to the Protocol to Eliminate Illicit Trade in Tobacco Products.⁸⁶ Most countries of the EMR have tobacco control laws.⁸⁷ However, the strength of such laws varies dramatically from a country to another.⁸⁸

The WHO Report on Global Tobacco Epidemic 2019 shows that out of the 22 EMR countries there are six countries that have recent, representative and periodic data on tobacco prevalence for both adults and youth; seven countries that have legislation banning smoking in all public places; three countries that have national quit line and both nicotine replacement therapy and some cessation services cost-covered; five countries that have large pictorial warnings on tobacco packages; four countries that have conducted national tobacco control campaign aired on television and/or radio; ten countries that have legislation banning all forms of direct and indirect advertising; and three countries that have a tax on retail price on the most popular brand of cigarettes higher than 75%.⁸⁹

Although the number of countries having such powerful tobacco control measures is not high, most of the EMR countries have at least some tobacco control measures. Most have implemented measures that puts them in the middle of their way to meet the comprehensive and recommended measures of tobacco control by the WHO FCTC. The report also shows that despite the existence of tobacco control laws, the compliance to such laws is challenging. For example, the report puts only one country in high compliance category out of the seven countries that have legislation banning smoking in all public places, and puts only five countries in high compliance category out of the ten countries that have legislation banning all forms of direct and indirect advertising. This compliance assessment highlights a huge gap in enforcement of existing legislation.⁸⁸

Stakeholders of tobacco control in the EMR includes governments, international intergovernmental organizations, non-governmental organizations, and academic institutes. Most countries of the EMR have a tobacco control unit within their ministries of health. Most international intergovernmental organizations that are accredited as observers to the COP are present in the EMR including the Arab League that 19 of the EMR countries are included in its members.⁹⁰ However the presence of non-governmental organizations accredited as observers to the COP is less noted in the EMR.⁹¹⁹²

Some academics in the region work in the field of tobacco control research with an example of the American University in Beirut hosting the Knowledge hub of FCTC on waterpipe.⁹³ The WHO is present in the region through the Tobacco Free Initiative Unit in their office for the EMR, in addition to tobacco control focal point in the organization’s country offices.⁹⁴

Industry interference

Published literature shows that the EMR has been suffering from tobacco industry interferences for many decades. Such interferences undermine efforts of tobacco control in the region leading to continuous high prevalence of tobacco use. ⁹⁵ The following are themes and examples of tobacco interferences in the EMR.

Illicit trade

The tobacco industry claims to combat illicit trade but that contradicts their overproduction in some markets and oversupplying to others and in the knowledge that excess tobacco will end up on the illicit market. In the region, the tobacco industry continued to supply the contraband trade despite appeals by the government to cease undermining its revenues.⁹⁶ The magnitude of illicit trade in both cigarettes and waterpipes is huge within the EMR with studies referring to the tobacco industry involvement either through the producers or the distributers of tobacco, using various routes to, from and across the region. ^{979899100101102}

Hijacking public health policies

The industry aims to undermine tobacco control efforts through their links to governments in the EMR.⁸⁰ For example the tobacco industry manoeuvrings to hijack the track and tracing systems of tobacco products in the EMR. Although, as discussed earlier, the links between the tobacco industry and illicit trade are studied and observed, there is still an ongoing process of signing memorandums of understanding between them and the governments in many of the EMR allowing the industry to have links with customs and giving them the opportunity to influence the new track and tracing systems.¹⁰³

Influencing taxation policies

Internal documents of the tobacco industry show their efforts in delaying the establishment of unified tax increases across the Gulf Cooperation Council’s countries that consists of six of the EMR countries; Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and United Arab Emirates.¹⁰⁴ An internal Philip Morris memo showed how they work strategically to influence the tobacco taxing system in Egypt through range of interferences including lobbying at all levels of the authorities.¹⁰⁵ In Pakistan, the tobacco industry did changes in cigarette prices at their advantage by shifting some of their most sold brands to the lowest tax slab allowing itself to manipulate the market by price setting.¹⁰⁶

Expanding of multinational companies

The expansion of multinational companies in the region as part of the industry’s strategy to shift from developed markets, where tobacco control policies are strong and smoking prevalence is declining, to emerging markets where demand for tobacco is higher and tobacco control legislations are weaker. Additionally, local companies such as Eastern Company in Egypt are expanding as well.¹⁰⁷ A prominent example for the expansion of multinational companies in the EMR is the increasing investments of Japan Tobacco International in the region. The company bought two major tobacco manufactures in the EMR: the Egyptian waterpipe company Nakhla and the Sudanese cigarette manufacturer Haggar, which gives Japan Tobacco access to export its products to 85 countries, mainly in the EMR and Africa.¹⁰⁸¹⁰⁹

Promoting Next Generation Products

The tobacco industry is aggressively promoting electronic nicotine/ non-nicotine delivery systems and heated tobacco products in the region and has already launched them in number of countries such as Kuwait.¹¹⁰ It is also expected that an international “vaping expo”, first of its kind, will be held in the United Arab Emirates in 2020 to frame the future of such products connecting manufacturers, distributors, and users of the products.¹¹¹ Although these products are being promoted globally by the industry, the case in the EMR is unique as electronic cigarettes were already banned in 11 out of the 22 countries of the region in 2017.¹¹² However, the situation is dramatically changing with Saudi Arabia, one of the leading tobacco control countries in the region, reverting its legislation and allowing electronic cigarettes, raising fears that a domino effect will take place allowing the product in the rest of EMR.¹¹³ The industry is using number of interferences to promote these products such as lobbying policy makers and targeting youth with false information and by adding favourable flavours to its products.¹¹⁴

Corporate social responsibility activities

Tobacco industry maneuvers to manipulate public opinion to gain the appearance of respectability happen across the countries in the EMR. For example, funding the education of women from Afghanistan in western universities by British American Tobacco;¹¹⁵ donating to cancer screening and treatment hospital in Egypt by Eastern Company for Tobacco;¹¹⁶ and funding projects for education in Pakistan, Jordan, Lebanon, Morocco, and Palestine by Philip Morris International.¹¹⁷ Additionally, the industry sponsor popular sports such as the Egyptian Eastern Company for Tobacco sponsoring a football team carrying its name and playing in the Egyptian football league.¹¹⁸Multinational companies also sponsor sport teams to brand their products such as British American Tobacco branding their electronic cigarette on McLaren cars (motorsports team) in the Bahrain Grand Prix, and Philip Morris International using Ducati (motorcycle team) for branding at the Qatar MotoGP.¹¹⁹

Use of influencers and allies

A clear example of this well-practiced tactic is the visit of prominent doctors from number of Egyptian medical schools to a Philip Morris International factory in Switzerland, and then posting on social media about the visit claiming that it was supported by the WHO to check a new product of the company that has no side effects. The WHO issued a press release to condemn the incident and to deny any support to such tobacco industry maneuvers. The doctors removed the post from social media after the WHO press release.¹²⁰The industry is also active in approaching universities to keep its presence among youth and to recruit best qualified graduates in the region to keep growing. For example, British American Tobacco is listed as partner to the American University in Cairo in conducting employment fairs, After conducting such meetings, BAT publish news about it, which gives the impression that they are linked somehow to this prestigious university.¹²¹⁶⁸

Generating industry-funded science

The tobacco industry use of research and policy forums is a well-known strategy to influence policy-making processes. In the EMR there is an example of funding research institute in Pakistan with thousands of dollars to conduct studies in the field of tobacco. This fund from the Foundation for a Smoke-Free World, which is a Philip Morris International funded organization. There are also examples of think tanks in the EMR that are allied with the tobacco industry which are the Egyptian Center for Public Policy Studies and the Pakistani Policy Research Institute of Market Economy. Both think tanks opposed plain packaging of tobacco products despite the fact that it is an evidence based public health tobacco control intervention.¹²²

Benefiting from emergencies and political instability

Tobacco industries look to use political instability as an opportunity to increase illicit trade and shape tobacco control policies in their favour. A number of countries in the region requested that tobacco control in protracted complex emergency situations should be an item for discussion during the COP of the WHO FCTC.¹²³ As a result of such discussion, the COP made a specific decision in this regard aiming to providing technical and financial assistance to countries in protracted complex emergency situations, and requesting countries to pay special attention to Article 5.3 of the WHO FCTC and related Guideline.¹²⁴

Tobacco Tactics resources

• JTI Involvement in Smuggling
• Gallaher Versus its Cypriot Distributor
• CSR Strategy
• Motorsport Sponsorship
• Foundation for a Smoke-Free World
• Think Tanks

References

The post Eastern Mediterranean Region appeared first on TobaccoTactics.