Image source: © Guillaume Piolle/CC BY 3.0

Key Points

• Lebanon is located on the eastern shore of the Mediterranean Sea. It is served by the World Health Organization’s Regional Office for the Eastern Mediterranean (EMRO).
• It has a population of 5.5 million, with an estimated tobacco use prevalence for those aged 15 and over of 39%.
• Lebanon ratified the WHO Framework Convention on Tobacco Control (WHO FCTC) in 2005. It has not ratified the Protocol to Eliminate Illicit Trade in Tobacco Products.
• Lebanon has a state-owned tobacco monopoly, the Regie Libanaise de Tabacs et Tombacs, known as the Regie, which controls the domestic market. Transnational tobacco companies only have access to the Lebanese market through the Regie.
• In recent years, tobacco industry lobbying has prevented the introduction of graphic health warnings; the Regie has sought to influence Lebanon’s delegation to the Conference of the Parties (COP) to the WHO FCTC; and the industry has conducted extensive corporate social responsibility activities, some of which have involved Lebanese state institutions.

Lebanon has some of the highest rates of tobacco use in the world. It is ranked third in the world for cigarette consumption per capita.¹ A 2019 survey also suggested that waterpipe use prevalence is particularly high, and higher amongst women than men.² Tobacco products were easily affordable until the start of Lebanon’s economic crisis in 2019.¹ Though they have become less affordable since then, the decline in affordability has been weaker compared to that for other goods.³ At just 9.9% of the retail price, the tax imposed on tobacco products falls well short of the 75% recommended by the World Health Organization (WHO).⁴⁵ Though a comprehensive tobacco control law was introduced in 2011, there have been major challenges with implementation and enforcement.⁶

Tobacco Use in Lebanon

In 2022, the population of Lebanon was 5.5 million.⁷ In 2019, the WHO estimated overall tobacco use prevalence to be 39% amongst the population aged 15 and over, based on all national survey data from 1990.⁸ An academic study carried out in 2019 found similar results. Based on a cross-sectional household survey, it found prevalence of cigarette smoking among adults aged between 18 and 69 of just over 35% (49% males; 21.5% females).² It also found overall waterpipe use prevalence of 39.5%, and at over 46%, prevalence for women was higher than for men (nearly 33%).² Almost half of current cigarette smokers reported smoking more than 20 cigarettes per day, while most waterpipe users smoked at least three sessions per week.²

In 2017, Lebanon reported tobacco use among boys aged 13-15 of 35% – the highest amongst the 19 EMRO countries which carried out the Global School-based Student Health Survey between 2001 and 2018.⁹ The corresponding figure for Lebanese girls that year was 28%.⁹ A study carried out amongst Lebanese adolescents aged 11 to 18 between 2016 and 2017 found ever use of waterpipe of 34%.¹⁰

There were an estimated 7,810 deaths attributable to smoking in 2019, accounting for over 23% of all mortality in Lebanon for that year.¹¹ A study published in 2014 put the economic burden of tobacco use in Lebanon in 2008 at US$326.7 million, or 1.1% of national GDP.¹²

A 2019 study on e-cigarette use amongst school and university students aged from 17 to 23 found that 14.5% reported ever use, with 8% reporting current use.¹³ However, at the time of writing, data on e-cigarette use amongst Lebanese adults remains scarce.

Tobacco in Lebanon

The Lebanese state tobacco monopoly

The Lebanese tobacco industry is controlled entirely by a state-owned company, the Regie Libanaise des Tabacs et Tombacs (referred to here as “the Regie”).¹⁴¹⁵ The Regie has exclusive rights to tobacco manufacturing and distribution, tobacco imports and exports, and to the purchase of locally grown tobacco leaf. It also oversees an anti-smuggling unit.¹⁶ The Regie distributes local and imported tobacco products to licensed wholesalers, at prices it determines with the Ministry of Finance (MoF).¹⁶¹⁷ These wholesalers then sell the tobacco products to retailers across Lebanon.¹⁶ Though these retailers are also licensed by the Regie, they are not under its direct control and largely depend on the wholesalers for their tobacco supply.¹⁶ The Regie sets the profit margin and weekly quota of sold tobacco for both wholesalers and retailers.¹⁶

Overseen by the MoF, the Regie’s performance has a direct impact on the public treasury.¹⁶ Not only does this provide the Regie with significant access to policy makers, it also creates conflict with other government departments (such as Health), as the MoF may oppose measures which damage the Regie’s profitability.¹⁶⁶

Market share and leading brands

As of 2022, the Regie had a share of over 55% of the tobacco market, up from 45% in 2017.¹⁸ The leading transnational tobacco company (TTC) in Lebanon was Philip Morris International (PMI), with a market share of nearly 15%, followed by Japan Tobacco International (JTI) on over 11%, Imperial Brands on almost 10%, and British American Tobacco (BAT) on 6.5%.¹⁸

Transnational tobacco companies (TTCs) only have access to the Lebanese market via the Regie. In return for purchasing Lebanese tobacco leaf, the Regie imports manufactured tobacco products to sell on the Lebanese market and buys Virginia tobacco leaf for the manufacture of local brand cigarettes.¹⁶ Since 2016, international brands have also been made in Lebanon at Regie manufacturing facilities, as per agreements with the Big Four TTCs.^19202122

The Regie brand Cedars is by far the most popular brand of cigarettes in Lebanon, with a market share of 55% in 2022.²³ PMI’s Marlboro is in second place with a share of around 14%.²³ JTI’s Winston is third (8%), followed by BAT’s Kent and Imperial Brands’ Gitanes (both around 5%).²³ All other brands have a market share of 3% or less.²³

Tobacco farming and child labour

In 2020, tobacco was being cultivated on 1.32% of Lebanon’s agricultural land.²⁴ In 2021, tobacco production was just over 10,000 tonnes, down slightly from a high of 12,800 tonnes in 2001.²⁵ This makes Lebanon the fifth-largest tobacco producer amongst the 14 EMRO countries for which data is available.²⁶

Lebanese tobacco leaf is purchased exclusively by the Regie via a price support programme, under which the Regie purchases from farmers at a given yearly price and quantity which is determined by the MoF.¹⁶ According to Hamade (2014), the price paid is well over the average paid to farmers in other sectors in Lebanon; essentially, it is a subsidy which reinforces farmers’ dependence on tobacco growing and disincentivises any transition towards other crops.¹⁴¹⁶

Lebanese tobacco featured on the 2022 List of Goods Produced by Child Labor or Forced Labor produced by the U.S. Department of Labor.²⁷ Tobacco production is very labour intensive and involves all or most members of the household, which includes women and children.¹⁴ On top of enduring poor wages and working conditions, female workers are also at risk of sexual violence in tobacco-growing communities.²⁸

• For information on tobacco industry responses to accusations of complicity in child labour, please see the pages on CSR: Child Labour and the Eliminating Child Labour in Tobacco-Growing Foundation (ECLT).

Tobacco and the economy

Lebanon is a net importer of raw tobacco. According to Comtrade data, in 2022, it imported over US$40.5 million in raw tobacco, compared to under US$16.4 million in exports.²⁹³⁰

Lebanon is also a net importer of cigarettes. In 2022, Lebanese cigarette imports were nearly US$16.5 million, compared to less than US$1 million in exports.³¹³²

It is also a net importer of waterpipe tobacco. Its imports were worth US$17.3 million in 2022, compared to exports of under US$70,000.³³³⁴

Illicit trade

Industry documents suggest that illicit trade was used by the TTCs as a means of building market share and furthering regional expansion during the Lebanese Civil War (1975-1990).³⁵ With governance weak and legal cigarette production in decline, the TTCs flooded the Lebanese market with cheap contraband products.³⁵ Though the government made direct appeals to these companies, requesting that they stop supplying distributors involved in this illicit trade, it had little effect.³⁵ The documents also show that the TTCs sought to use the issue of illicit trade as leverage in negotiations on establishing manufacturing presence in the country.³⁵

Today, reliable data on the scale of the illicit trade in Lebanon are not available. An industry-funded report by the consultancy Oxford Economics (OE) indicated that by the first quarter of 2019 the illicit trade accounted for 28.1% of the market in tobacco products.³⁶³⁷ However, this data may not be reliable given OE’s long relationship with the tobacco industry. Not only was this particular study funded by PMI, BAT and JTI, but also prepared according to terms of reference agreed with all three companies.³⁷ These terms of reference are not disclosed, while the methodology used is highly susceptible to industry interference.³⁸

Exaggerating the scale of illicit trade is a well-documented tactic which has been used by the tobacco industry all over the world as a means of opposing tobacco control regulations. See Illicit Tobacco Trade for further details.

• For more information on the tobacco industry in Lebanon, please see the Tobacco Supply Chain Database.

Roadmap to Tobacco Control

Lebanon ratified the WHO FCTC in 2005.³⁹ It has yet to ratify the Protocol to Eliminate Illicit Trade in Tobacco Products.⁴⁰

In August 2011, Lebanon passed Law No. 174, its first ever tobacco control law.⁶ This was the result of years of advocacy led by the National Tobacco Control Program (NTCP) (a government organisation within the Ministry of Public Health), alongside academics, tobacco control advocates, civil society organisations, local and international NGOs, and policy makers.⁶ Law No. 174 banned smoking in all indoor public spaces; banned tobacco advertising, promotion and sponsorship; and introduced larger text warnings on tobacco products, with the potential to add graphic health warnings at a later date.⁶

However, enforcement remains a challenge, particularly regarding the provision for smokefree spaces. This measure was properly enforced for just three months, thanks in part to strong lobbying from restaurants and other establishments offering waterpipe.⁶ There has also been a lack of political will to enforce the law.⁶ In late 2012, the then Minister of the Interior implied that the police would be flexible about enforcing the law during the holiday period.⁴¹ The Ministry of Tourism also stopped enforcing the law, alleging a negative impact on Lebanon’s tourist industry and stating that it did not have the resources necessary to monitor implementation.⁶⁴²

For more details, please see the following websites:

• Legislation by country – Lebanon, Tobacco Control Laws, Campaign for Tobacco Free Kids
• Lebanon, WHO FCTC Implementation Database, WHO FCTC Secretariat
• Country profile – Lebanon, World Health Organization, WHO report on the global tobacco epidemic 2021

Tobacco Industry Interference in Lebanon

Tobacco industry tactics in Lebanon include lobbying, which has prevented the introduction of graphic health warnings; attempting to influence Lebanon’s delegation to the Conference of the Parties (COP) to the WHO FCTC; and corporate social responsibility.

Portraying tobacco as a symbol of resistance

Part of the revenue the Regie collects from imported tobacco products is used to cover the subsidies given to tobacco growers in rural areas, particularly in the south of the country.¹⁶⁶ Given that this area was previously occupied by Israel, keeping farmers on this land is seen by the state as an important geopolitical objective.⁶ Indeed, both Nassif Seklaoui, Chairman and General Manager of the Regie, and the speaker of the Lebanese parliament, have explicitly linked tobacco growing to the struggle of the Lebanese people and their resistance to foreign occupation.⁴³ Such strategies aim to instil the belief that tobacco is a strategic industry and a source of national pride. As the opening statement of a Regie pamphlet from 2011 reads, “The tobacco crop has become a symbol of resilience, resistance and people’s attachment to the Nation’s land.”¹⁴

Influencing policy: health warnings

Law 174 significantly increased the size of the textual health warnings on tobacco products in Lebanon, from 15% to 40% of the principal surface areas.⁶⁴⁴ A further decree in 2012 defined the text of the warnings, though implementation was delayed, reportedly due the Regie lobbying the Minister of Finance.⁴⁵⁴⁶ Since then, the larger text warnings have been widely implemented – though the measure still falls short of the 50% or more coverage recommended by the WHO FCTC.⁴⁷⁴⁸

Law 174 did also allow for the introduction of graphic health warnings (GHWs) at a later date, subject to the signing of an implementation decree by the Ministry of Health and the Ministry of Finance.⁴⁷ According to Lebanese tobacco control advocates, of all provisions in Law 174, this was the hardest to obtain, due to fierce opposition from the tobacco industry, including the Regie.⁴⁶ During discussions on Law 174 in 2011, some members of the Lebanese parliament objected to the inclusion of GHWs, echoing industry positions on the issue.⁴⁶ Though the implementation decree for GHWs was elaborated in 2011 and updated in 2016, it has still not been approved, reportedly due to industry interference and lobbying.⁴⁷ As of 2021, GHWs had yet to be implemented.⁴⁹

Interacting with the Lebanese delegation to the COP

In 2018, the Regie hosted a meeting attended by six government officials at its headquarters, ahead of the Eighth Session of the Conference of the Parties (COP8) to the WHO FCTC. In the Regie’s own words, the meeting aimed to define a position that “addresses the threats that the items on COP8 agenda for next October pose to tobacco sector”.⁵⁰ There was also a presentation laying out the Regie’s positions on decisions made at the previous COP, as well as the proposals to be discussed at COP8.⁵⁰

Delivering this presentation, Mariam Hariri, the Regie’s Head of General Management, stated:

“We cannot look at tobacco sector only from the perspective of health damage; we must rather look at it with a comprehensive and impartial view. We must take into consideration the economic benefits it offers and the specificity of Lebanon.”⁵⁰

This meeting contravened the implementation guidelines for Article 5.3 of the WHO FCTC, which urge parties to limit interactions with the tobacco industry to those strictly necessary for effective regulation of the industry and its products.⁵¹

The Regie has also lobbied foreign diplomats. In May 2022, the German ambassador to Beirut visited Regie headquarters in Hadath. He was briefed on “the Regie’s achievements in agricultural, industrial, and commercial fields, among others, as well as about the societal role that it had played during the recent years.”⁵²

• For more on the relationship between diplomats and the tobacco industry, please see Diplomats Lobbying for Tobacco Companies.

Corporate social responsibility

In 2016, the Regie launched its sustainable development plan, entitled “Development Vision for a Brighter Tomorrow”. Its stated aim was “promoting economic development, environment protection, fighting illicit trade & child labor, and improving the living of workers & farmers and the communities where we operate.”⁴³ The plan was launched at a ceremony which was supported by the speaker in the Lebanese parliament, and attended by notable figures from business, politics, finance and the trade union movement.⁴³ These included senior civil servants from government departments including the Ministry of Finance, the Ministry of Economy and Lebanese customs.⁴³

Since then, the Regie has conducted extensive CSR activities, including some directed at or involving Lebanese state institutions. For example, it donated US$2.6 million to the Lebanese Army in 2021.¹⁶ It also engaged in CSR during the COVID-19 pandemic, donating US$1 million to the Lebanese government to support repatriating Lebanese students abroad and to buy ventilators for COVID-19 patients.⁵³

The Regie has also organised “women empowerment training sessions” for the daughters of tobacco farmers in different areas of Lebanon. These sessions had the support of local authorities; for example, some were held in municipal buildings or involved the participation of local councillors.⁵⁴⁵⁵

The Regie has also carried out CSR in partnership with TTCs. In 2017, in an initiative financed by PMI Lebanon, the Regie offered scholarships to 136 children of tobacco farmers in the north of the country – the fourth consecutive year it had done so.⁵⁶

• For more on tobacco industry activity during the pandemic, please see the COVID-19 Tobacco Tactics page and the COVID-19 monitoring database.

Relevant Links

• AUB tobacco researchers and Lebanese activists press conference on economic impacts of Law 174: The tobacco control law is good for the economy and public health, American University of Beirut
• Prevalence of cigarette and waterpipe tobacco smoking among adults in three Eastern Mediterranean countries: a cross-sectional household survey, R. Nakkash, Y. Khader, A. Chalak, R. Abla, N. M. E. Abu-Rmeileh, A. Mostafa, M. Jawad, J. H. Lee and R. G. Salloum, BMJ open, 2022, 12(3), e055201
• The passage of tobacco control law 174 in Lebanon: reflections on the problem, policies and politics, R.T. Nakkash, L. Torossian, T. El Hajj, J. Khalil and R.A. Afifi, Health Policy and Planning, 2018, Volume 33, Issue 5, pp. 633–644
• K2P COVID-19 Series: Prompting Government Action for Tobacco Control in Lebanon during COVID-19 Pandemic, R. Saleh, R. Nakkash, A. Harb and F. El-Jardali, 2020, Knowledge to Policy (K2P) Center, Beirut, Lebanon
• The Economics of Tobacco in Lebanon: An Estimation of the Social Costs of Tobacco Consumption, Salti, J. Chaaban and N. Naamani, Substance Use & Misuse, 2014, 49:6, 735-742

Tobacco Tactics Resources

• Eastern Mediterranean Region
• Oxford Economics
• Tobacco Farming

TCRG Research

• The Lebanese Regie state-owned tobacco monopoly: lessons to inform monopoly-focused endgame strategies, H. Alaouie, J.R. Branston and M.J. Bloomfield, 2022, BMC Public Health, 22, 1632.
• Developing more detailed taxonomies of tobacco industry political activity in low-income and middle-income countries: qualitative evidence from eight countries, B.K. Matthes, K. Lauber, M. Zatoński, L. Robertson, A.B. Gilmore, BMJ Global Health 2021;6:e004096.
• Tobacco industry commissioned reports on illicit tobacco trade in the Eastern Mediterranean Region: how accurate are they? Sandberg, A.W.A. Gallagher and R. Alebshehy, 2020, Eastern Mediterranean Health Journal, 26(11):1320–1322.

For a comprehensive list of all TCRG publications, including research that evaluates the impact of public health policy, go to TCRG publications.

References

The post Lebanon Country Profile appeared first on TobaccoTactics.

There have been multiple instances of lobbying by ambassadors and other diplomats from the UK, as well as Japan and Switzerland. Much of this lobbying activity has taken place in low and middle-income countries (LMICs).⁵⁸ These countries are important sources of new customers for tobacco companies as markets in higher income countries where consumption is generally falling.⁵⁹⁶⁰⁶¹

Diplomats are also involved in activities which help promote the tobacco industry via local media, such as visiting tobacco farms or factories. Other engagement supports tobacco companies’ product promotions, or corporate social responsibility strategy. These activities help to raise the profile of tobacco companies, enhance their reputations, and support the ‘normalisation’ of the industry.⁵⁷⁶²⁶³

Background

Parties to the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) have an obligation to protect public health policies from the “commercial and vested interests of the tobacco industry” and any contact with tobacco industry representatives, or others seeking to further their interests, must be “limited” and “transparent”.⁶⁴ The implementation guidelines to Article 5.3 of the WHO FCTC recommend that Parties limit interactions with the tobacco industry to those that are absolutely necessary to regulating the industry, and ensure the transparency of those interactions that do occur.⁶⁴  The guidelines also recommend parties treat state-owned tobacco companies in the same way as any other tobacco company, including avoiding any “preferential treatment”.⁶⁴

In addition, the guidelines state that “… Whenever possible, interactions should be conducted in public, for example through public hearings, public notice of interactions, disclosure of records of such interactions to the public”.⁶⁴

However even in countries with a high level of compliance with the WHO FCTC requirements, diplomatic missions rarely achieve this level of transparency. Information on tobacco industry engagement has largely been found through media investigations and Freedom of Information requests (FOIs).

In October 2014, the 6^th Conference of the Parties (COP) decided to urge parties: “to raise awareness and adopt measures to implement Article 5.3 and its implementing Guidelines among all parts of government including diplomatic missions.”⁶⁵ Another decision required governments to “take into account their public health objectives in their negotiation of trade and investment agreements”.⁶⁶

Nevertheless, diplomats continue to lobby for tobacco companies around the world.⁵⁷

Countries whose diplomatic representatives have lobbied on behalf of tobacco companies overseas  include the UK, Germany and Japan, who are all Parties to the WHO FCTC,⁶⁷ as well as the United States and Switzerland. BAT, PMI and Japan Tobacco all have offices in Geneva, Switzerland, the location of the World Health Organization and other key international bodies.

UK

There are specific guidelines covering the engagement of British (UK) officials working overseas designed to limit contact with tobacco companies, and support compliance with Article 5.3. After the UK Ambassador to Panama lobbied on behalf of British American Tobacco (BAT),⁶⁸ the guidelines were revised in 2013.⁶⁹ These guidelines state that “Posts must not…Engage with local foreign governments on behalf of the tobacco industry, except in cases where local policies could be considered protectionist or discriminatory”.⁶⁹

Engagement and lobbying

Despite having guidelines in place to support compliance with the WHO FCTC, FOI requests and media investigations have revealed that British diplomats continue to interact with the tobacco industry more than is necessary. UK diplomats have lobbied for BAT in Bangladesh,⁷⁰⁷¹ Hungary,⁷² and Pakistan.^6873747576

UK officials have also disclosed contact with tobacco companies in Panama and Venezuela,⁷⁷⁷⁸ Laos,⁷⁹ Cuba,⁸⁰ and Burundi.⁸¹

In 2018, UK advocacy organisation Action on Smoking & Health (ASH) called this a “global pattern of engagement” by British officials to defend BAT’s interests.⁸²

• For more details see UK Diplomats Lobbying on Behalf of BAT.

Tobacco industry events

UK government guidelines state that staff must not:

“Attend or otherwise support receptions or high-profile events, especially those where a tobacco company is the sole or main sponsor and/or which are overtly to promote tobacco products or the tobacco industry (such as the official opening of a UK tobacco factory overseas)”.⁶⁹

However, UK staff have attended such events, generating considerable local media coverage.

For example, in 2019 the British ambassador to Yemen opened a cigarette factory in a free trade zone in Jordan, celebrating the expansion of the tobacco company Kamaran which is part-owned by BAT.^57838485

In 2020, staff from the UK high commission in Pakistan attended a promotional event for a BAT product in Pakistan.⁸⁶

• See UK Diplomats Lobbying for BAT for details.

Engaging with industry allies

The links between diplomatic missions and tobacco companies can be more indirect, via funding third party allies of the industry. The UK guidelines state that diplomats should not “endorse projects which are funded directly or indirectly by the tobacco industry”.  However, a 2019 investigation by The Guardian found that the British high commission in Malaysia had given funding to a Kuala Lumpur based think tank (IDEAS) for several years. At the same time the think tank was also receiving money from tobacco companies and was lobbying against plain packaging regulation and tobacco taxes.⁸⁷  While the UK had already implemented plain packaging regulations, tobacco control was being undermined overseas.

Attending meetings with the tobacco industry

Tobacco companies attend meetings and events organised directly by UK government departments, such as the FCO (now FCDO) or the DIT (now Department for Business and Trade).⁷⁷  They also attend those held by regional, national or local business organisations such as chambers of commerce.

Responses to FOI requests show that when the attendance of UK government officials at such events is disclosed, there is little detail about the specific purpose or content of these meetings,⁷⁰⁷² It may simply be described as relating to ‘doing business’ in the country.⁷⁸

Business vs public health interests?

The UK guidelines for overseas staff (last updated in 2013) allow for the communication of “basic trade, investment and political information”, although this is not defined.⁶⁹ One of the activities used to justify interaction by UK diplomats is “resolving business problems that are potentially discriminatory”.^6870728889 This has been criticised as running counter to the WHO FCTC guidelines.⁵⁷⁹⁰

While transparency is required for tobacco industry interactions in 2018, the UK government told Parliament that it “does not catalogue the representations it makes on behalf of companies”.⁹¹⁹²⁹³  Research by the Tobacco Control Research Group (TCRG) concluded that the stated WHO FCTC goal of “maximum transparency” is not being achieved in the UK.⁵⁷⁸⁵

Japan

In 2021, the Ambassador of Japan to Bangladesh lobbied the government of Bangladesh on behalf of Japan Tobacco International (JTI).  In a letter to the Bangladesh Finance Minister the Ambassador criticised 2019 taxation changes for their impact on JTI. It also complained about the activities of competitors, and licensing demands.⁹⁴

• For details, including the lobbying letter, see Japanese Diplomats Lobbying for JTI

The Japanese Ambassador to Ethiopia was present at the signing of a deal between the Ethiopian government and JTI in 2016,  when the Ministry of Public Enterprise sold 40% of its National Tobacco Enterprise to the Japanese company.⁹⁵ Japanese diplomats have also toured tobacco farms and JTI factories in Tanzania and Zambia.⁹⁶⁹⁷

Japan Tobacco International is the overseas subsidiary of Japan Tobacco (JT), which is one third-owned by the Japanese government.⁹⁸

Germany

In May 2022, the German ambassador to Beirut visited the offices of Regie, the Lebanese Tobacco and Tobacco Inventory Administration.⁵⁷⁹⁹

Denmark

The Imani Centre for Policy and Education, a Ghana-based think tank,  received money from the Danish embassy while lobbying against tobacco control.⁸⁷¹⁰⁰

Switzerland

Switzerland is not Party to the WHO FCTC.

In 2019, Swiss diplomats approached the government of the Republic of Moldova on behalf of Philip Morris International (PMI) seeking an opportunity to discuss new tobacco legislation.^101102103  The proposed legislation included significant tax increases on heated tobacco products, in which PMI has invested.¹⁰¹¹⁰⁴

The same year, PMI helped fund an inaugural event for the new Swiss Embassy in Moscow.¹⁰⁵¹⁰⁶

• For more details see Swiss Diplomats Lobbying for PMI

USA

Although the US is not Party to the WHO FCTC, it has specific laws and guidance that prohibit its diplomats from promoting the sale or export of tobacco, or influencing non-discriminatory restrictions on tobacco marketing.^107108109110 However, US diplomats have enabled meetings between tobacco companies and government representatives.

The US ASEAN Business Council organises delegations of US businesses, including Philip Morris International (PMI), which meet high level officials in the ASEAN region.¹⁰⁷  PMI was at the time a vice chair of its Customs & Trade Facilitation Committee and used this opportunity to meet with government officials from the Ministry of Industry and Trade of Vietnam.¹⁰⁷¹¹¹

Why it matters

The examples above illustrate contraventions of the WHO FCTC, an international treaty, and in many cases breaches of national guidelines. As TCRG research points out, all of these activities also undermine the spirit of these laws, by apparently serving the commercial interests of transnational tobacco companies and helping to ‘normalise’ the industry in the eyes of policy makers and the public.⁵⁷

The implementation guidelines of Article 5.3 urge Parties to exclude the tobacco industry completely from the public health policy arena.  The guidelines also urge them not to participate in corporate social responsibility (CSR) activities which are used by the tobacco industry and as an alternative means to access policy makers, as well as for public relations and product promotion.⁵⁷

In August 2019, in direct response to the exposure of lobbying by Swiss diplomats, the WHO released a statement urging governments to comply with Article 5.3 and to “proactively aspire to reduce the number of people starting and continuing smoking, to promote health and preserve future generations”.¹¹²

TobaccoTactics Resources

• UK Diplomats Lobbying for BAT
• UK Diplomats Lobbying for BAT: Bangladesh
• UK Diplomats Lobbying for Tobacco: Burundi
• Swiss Diplomats Lobbying for PMI
• Japanese Diplomats Lobbying for JTI
• Third Party Techniques

TCRG Research

A “willingness to be orchestrated”: Why are UK diplomats working with tobacco companies?, R. Alebshehy, K. Silver, P. Chamberlain, Frontiers in Public Health, 17 March 2023, Sec. Public Health Policy, Volume 11 – 2023, doi: 10.3389/fpubh.2023.977713

For a comprehensive list of all TCRG publications, including TCRG research that evaluates the impact of public health policy, go to the Bath TCRG’s list of publications.

References

The post Diplomats Lobbying for Tobacco Companies appeared first on TobaccoTactics.

• Menthol and flavoured cigarettes are widely available in low and middle-income countries (LMICs) many of which have high smoking rates
• LMICs have young populations – flavours appeal to young people, who may not understand the harms of flavoured tobacco
• Recently high-income countries have put bans in place; at the same time there has been marked growth of menthol market share in some LMICs
• There is a lack of regulation to reduce the appeal of flavours e.g. plain packs and advertising bans at point-of-sale or near schools
• Targets for new and improved bans include flavour capsules, and flavour references on packaging and cigarette sticks
• A ban on all flavourings may be easier and more effective in preventing product substitution
• A lack of data, especially in low-income countries, hinders the development of good regulation
• Multinational tobacco companies can threaten income from tobacco exports if governments attempt to put tobacco controls in place

This page covers flavoured tobacco, including menthol cigarettes, in low and middle-income countries (LMICs).¹¹⁷¹¹⁸

Background

Flavoured tobacco products are available in various forms around the world, including products previously only used in particular regions or countries. For example in Indonesia, the vast majority of smokers use kretek, clove-flavoured cigarettes,¹¹⁹¹²⁰ and they are now available in other countries.¹²¹¹²²

Flavoured tobacco is used in waterpipe, a device which originated in middle-eastern countries and is increasingly popular elsewhere, including among young people.¹²³

Here we focus on what are often called ‘conventional’ products, like cigarettes and cigarillos, which are sold by large transnational tobacco companies (TTCs): Philip Morris International (PMI), British American Tobacco (BAT), Imperial Brands (IMB, previously Imperial Tobacco) and Japan Tobacco International (JTI) (JTI also owns Nakhla in Egypt, which produces flavoured waterpipe) We summarise findings from Tobacco Control Research Group (TCRG) research on the extent of flavoured and menthol cigarette use in LMICs and the development of the market for ‘capsule’ products (cigarettes with flavour capsules in the filter).

We describe specific challenges for LMICs, including flavour regulation and evidence gathering. We then summarise flavour market evidence and research, first relating to LMICs in general and then by World Health Organization (WHO) region and individual countries (where available).

• For general background and evidence, including information on the global market, and details of specific bans and associated industry interference, see Flavoured and Menthol Tobacco.

For details of product regulation at country level, see the searchable database on the Tobacco Control Laws website, published by the Campaign for Tobacco Free Kids (CTFK). For countries that are parties to the WHO Framework Convention on Tobacco Control (FCTC) progress towards implementation of relevant articles, including newer products, is detailed in the FCTC implementation database

Specific challenges for LMICs

LMICs with no ban often have other major tobacco control policy gaps that are not necessarily menthol/flavour related but worsen the negative impact of menthol/flavours.¹²⁴ One such policy is plain, or standardised, packaging,  which can include restrictions on flavour descriptors as well as colours on packaging which are known to signify flavour (e.g. green for menthol).¹²⁵ However, plain packaging policies have yet to be implemented in many countries, including some high-income countries, so this would be a significant challenge in LMICs. Another relevant policy is the prohibition of marketing, especially near schools.¹²⁶

Governments have more conflicts of interest in tobacco growing areas as they receive much needed foreign currency for tobacco exports,  and multinational companies can threaten this income stream if governments attempt to put tobacco controls in place.¹²⁴¹²⁷  However, apart from rare exceptions the tobacco industry contributes little overall to the balance of payments.¹²⁸¹²⁹

Regulatory challenges

The WHO published brief guidance on the regulation of menthol and flavoured tobacco which summarised some regulatory options including restrictions on: the sale of menthol branded products,  the use of menthol at noticeable levels (giving a ‘characterising flavour’),  or banning any menthol ingredients.¹³⁰  The report points to likely opposition from the tobacco industry in countries or regions with an established menthol market.¹³⁰ This was the case with the European Union (EU) menthol ban which only came into full force in 2020, after the tobacco industry had successfully lobbied for a delay. Testing for characterising flavour is more difficult and expensive than a ban on ingredients; this makes banning menthol as an ingredient particularly efficient for LMICs.

The WHO noted that:

“A ban on all flavour agents that increase tobacco product attractiveness, rather than focusing on menthol exclusively, can provide an alternate route to restricting menthol, and may prevent the unwanted introduction of menthol substitutes.”¹³⁰

Research and data

As of 2021, when TCRG researchers conducted a review of evidence on menthol/flavour in LMICs,¹³¹ there were very few research papers from countries in Eastern Europe, the Eastern Mediterranean region, and Africa.

Lack of data means that it is hard to monitor markets and company shares in specific countries.  Market research service Euromonitor (which receives project funding from Philip Morris International) includes no low-income countries and is proprietary, making it expensive and hard to access even for the middle-income countries which are included.

More research is needed on menthol and flavour in LMICs to help governments monitor the tobacco industry and its products, as recommended by the WHO: “An evidence base using data collected from the region of interest can provide more direct support for regulation.”¹³⁰

Market in LMICs

Evidence suggests menthol and flavoured tobacco products are widely used in LMICs.  Data from the International Tobacco Control (ITC) Policy Evaluation Project suggests that menthol is smoked by more than 20% of smokers in several middle-income countries. Although the dates vary (see the note above on data challenges) this research gives an indication of the scale of the problem. The highest rates were found in Zambia (42% in 2014) and Thailand (35% in 2012). Kenya and India also had over 20% menthol smokers, with China just under just under that level.¹³²

A study from Johns Hopkins University, between 2015 and 2017, found a range of flavoured and capsule cigarettes on the market in those LMICs with the highest number of smokers: Bangladesh, Brazil, China, India, Indonesia, Philippines, Russia, Thailand, and Vietnam.¹³³

The main TTCs operating in these countries (PMI, JTI, and BAT) mostly sold menthol or mint flavours. China National Tobacco Corporation (CNTC) sold  a mix of flavours.¹³³

There is also evidence from a number of studies that menthol and flavour tobacco use is rising, either as a proportion of the market or substantively.  Evidence from TCRG research shows that after the implementation of the European Union (EU) menthol ban in 2020, there was a marked increase in the share of menthol/flavoured products in some LMICs.¹³¹ A study of cigarette packs in Brazil, Indonesia, the Philippines, Russia, Thailand, and Vietnam, between 2013 and 2016, found that the number of flavour capsule variants on the market was growing.¹³⁴ Most were mint and menthol flavour but with others the flavour was unclear from the product name.¹³⁴

A number of studies have identified related marketing activities.  Marketing strategies for flavour capsules are likely driving their global growth particularly among young people in LMICs.¹³⁵

TCRG’s review  of tobacco industry strategies underpinning the growth of menthol/flavoured tobacco use in LMICs  highlighted widespread marketing in stores (including retailers near schools), on billboards, on TV, online and via brand ambassadors. The packaging of flavoured and menthol products, legally displayed in stores, was  found to be colourful with non-conventional, appealing names for flavours.¹³¹

Tobacco companies also use symbols on cigarette sticks to indicate that they contain capsules.¹³⁶ Researchers studying this form of marketing in LMICs have described the space on a cigarette as “valuable communicative real estate” for tobacco companies, which could be better used to display public health messages.¹³⁶

Research and data from specific regions and countries is summarised below. We refer in many places to TCRG research based on 2019 cigarette market data from Euromonitor. In this data ‘high market share’ means 20% or more of the total cigarette market in that country in 2019. ‘High market share growth’ means that the share doubled between 2005-19 and was growing from 2017.¹³¹ We link to regional and country profile pages on TobaccoTactics, where available.

Africa

Nigeria has high menthol/flavour market share and high market share growth.¹³¹

Cameroon has high market share, the only other country in the region for which this data was available. (For Egypt see Eastern Mediterranean region below.)¹³¹

Tanzania

JTI sells a menthol cigarette called Sweet Menthol through its subsidiary in Tanzania. It describes this product as “the leading local mainstream menthol brand”.¹³⁷

Zambia

JTI owned brand Sweet Menthol is the third most popular cigarette in Zambia.  It is cheap and is usually sold as single sticks.¹³⁸  On its webpage for Zambia, JTI describes itself  as a leaf farming company, and does not mention that it sells cigarettes in the country. A locally owned company, Roland Imperial,  also sells menthol cigarette brands.¹³⁹

ITC survey data showed a high prevalence of menthol smokers in Zambia, with 43% of smokers choosing the product.¹⁴⁰ Menthol was most commonly used among younger smokers, those with a middle income, and those that don’t smoke every day. Over a third of smokers indicated that they thought menthol cigarettes were less harmful than non-menthol.¹⁴⁰

Kenya

ITC survey data from Kenya also suggests a high prevalence of menthol smokers.¹⁴⁰¹⁴¹ In 2018, 21% of smokers with a regular cigarette brand smoked menthol or sweet menthol (although Euromonitor estimates that only 7% of cigarette sales are menthol).¹³¹  More women smoke menthol than men in Kenya, and two thirds of smokers believed that menthol is less harmful than other cigarettes.¹⁴⁰¹⁴¹

Ethiopia

In 2015, Ethiopia enacted a total flavour ban on all forms of tobacco.

• For details see Flavoured and Menthol Tobacco

This was a pre-emptive ban as flavour sales were low. However there has been a lack of enforcement at the retail level.¹²⁴ Flavoured products are not made in Ethiopia and more collaboration with customs is needed to prevent illicit importation.¹²⁴ There is also a lack of awareness that the ban includes waterpipe products.¹³⁰

Since 2017, two years after the ban was enacted, JTI has owned 70%  the state owned tobacco company, NTE.¹⁴²

Latin America

Menthol cigarettes are popular in Latin America, and increasingly so in some countries.¹³¹ Guatemala and Peru have high market share and high market share growth. There is high market share in Columbia and the Dominican Republic, and high market share growth in Argentina, Bolivia and Costa Rica.¹³¹

Use of flavour capsule cigarettes is particularly high in Chile and Mexico.¹⁴³  According to BAT’s annual report in 2014,  sales of  flavour capsule cigarettes had increased in the region despite price rises, while overall cigarette sales were down.¹⁴⁴

A study of over 1,000 retailers located close to schools in Latin American cities (Argentina, Bolivia, Brazil, Chile and Peru) found that the majority (85%) sold flavoured cigarettes, and most (71%) sold capsule versions.¹²⁶ (Similar findings were reported in Uruguay, a high income country, immediately before the implementation of plain pack regulations in 2020.)¹⁴⁵

These products were frequently displayed near the point of sale, or confectionary. Some stores also had advertisements and price promotions.¹²⁶ Unconventional flavour descriptors such as “fusion blast” and “ruby ice” were very common.¹⁴⁶

Brazil

Survey data from 2016-2017 among adult smokers in Brazil found that over 50% supported a ban on menthol and over 60% supported a ban on all additives.¹⁴⁷ Support did not vary across sociodemographic groups. When menthol smokers were asked what they would do if menthol cigarettes were banned, a third reported they would quit, around 20% would reduce the amount they smoked and a similar number would switch to non-menthol cigarettes. Slightly fewer said they would still find a way to get menthol cigarettes.¹⁴⁷

ITC survey data from the same period suggested that 8% of smokers with a regular cigarette brand smoked menthol.¹⁴⁸ 13% believed that menthol cigarettes were less harmful than non-menthol cigarettes, and over a third reported that they were smoother on the throat and chest.  Nearly two thirds  of surveyed smokers supported a complete ban on all cigarette additives, including flavourings.¹⁴⁸

An online sample of women aged 16- 26 (smokers and non-smokers) preferred packs with flavour descriptors.¹⁴⁹

• The tobacco industry has used a range to tactics to undermine and delay Brazil’s menthol ban. For details see Flavoured and Menthol Tobacco

Chile

In 2013, Chile sought to implement a law banning substances that cause higher levels of addiction, harm or risk, leading to tobacco industry resistance and interference.¹³⁰

• For details see Flavoured and Menthol Tobacco

Mexico

Studies of retailers in Mexican cities, found that the majority sold menthol and flavoured products, and more than half of stores situated near schools sold flavour capsule cigarettes.¹⁵⁰¹⁵¹ Many flavoured cigarettes have descriptors which suggest there is a flavour, but the type of flavour is unclear: chemical analysis of dual flavoured cigarettes suggested flavours were menthol and another flavour, for example fruit.¹⁵²

A study in Mexico City found that colour and flavour descriptors on cigarette packs made the products more appealing, and some smokers believed they would taste better.¹⁵³

Guatemala

A study of convenience store retailers in Guatemala found that all sold flavoured tobacco products.¹⁵⁴

The majority (88%) of indoor tobacco advertisements in Guatemala were found to be for capsule cigarettes.¹⁵⁴

South East Asia & Western Pacific

There is high market share of menthol/flavour in India, Malaysia, Philippines and Thailand, and high market share growth in Vietnam.¹³¹  A 2010 study noted that governments in the region had no legislation banning exotic flavours of cigarettes and cigarettes with new flavours had appeared in Cambodia, Indonesia, Malaysia and the Philippines.¹⁵⁵

Philippines

Menthol has been advertised to appeal to young women in the Philippines since the 1970s with menthol brands common for many decades.¹⁵⁶ PMI, JTI, BAT and Korea Tobacco & Ginseng (KT&G) all sell flavoured capsule cigarettes in the Philippines.¹⁵⁷

Menthol packs studied in the Philippines were harder than non-menthol (for capsule protection) giving a quality feel. Flavoured capsule brands had a greater technological appeal,¹⁵⁷ and packs were rated as more attractive by young adults.¹⁵⁸

Blue and white packs were perceived to be less harmful than other colours, as were the descriptors ‘light’ and ‘cool’, whereas the term ‘strong’ was perceived as more harmful.¹⁵⁸  Researchers called for greater action and support for banning flavour additives.

Malaysia

In Malaysia, menthol cigarette marketing has been aimed at young people and women.  In the 1980s Brown and Williamson’s Newport menthol cigarettes were marketed in Malaysia with youthful American images and were sold at a cheap price point.¹⁵⁹ An internal document from 1993 reveals how the company was developing sweet and fruit flavours for the Malaysian market. ¹⁵⁹¹⁶⁰ A 2003 study noted that the menthol variant of Cartier Vendome (a BAT brand at the time) was described as ‘pearl tipped’ so likely to appeal to women.¹⁶¹

In 2013, vanilla, mint and fruit flavoured cigarettes were on sale, and strawberry cigarette packs with pink packaging were documented.¹⁶²

China

In China ‘flavour capsule’ was found to be one of the most common cigarette terms used in online tobacco marketing.  One website explicitly linked flavour capsules with female smokers.¹⁶³

Indonesia

In Indonesia the dominant cigarettes are kreteks which are flavoured with cloves.  Industry attempts to introduce their own cloved flavoured products had failed at least to 2004.¹⁶⁴  In 2009 PMI and BAT acquired two domestic manufacturers which allowed them access to the kretek market.¹⁶⁵ In 2009 PMI launched the first super slims kretek for women and Marlboro black menthol for young men.  By 2012 BAT had launched several kretek brands. Both companies were aware that kreteks  are particularly carcinogenic due to the presence of toxic chemical compounds: Anethole, Coumarin and Eugenol.¹⁶⁵

In Indonesia the flip lid of the cigarette packet was used by Esse (owned by Korean Tobacco & Ginseng, KT&G) to promote the brand with phrases evoking flavour, like “sweet surprise” and “its honey”.  Research found seven cigarette brands with capsules.  Flavours included mint, menthol, berry and honey.¹⁶⁶

Eastern Mediterranean

There is high market share growth in in Pakistan and Egypt .¹³¹

• See also Waterpipe for information on the role of flavours in promoting these products.

Eastern Europe

Data shows that in Russia menthol/flavour has both a high market share and high market share growth.¹³¹

Other LMICs in the region with high market share growth are Ukraine, Bosnia Herzegovina, Belarus, Azerbaijan, Kazakhstan and Uzbekistan.¹³¹

Relevant Links

WHO Advisory note: banning menthol in tobacco products (2016)

WHO Case studies for regulatory approaches to tobacco products: menthol in tobacco products (2018)

WHO FCTC decision on banning waterpipe flavour (2016)

A global map of menthol bans is available on Tobacco Atlas: Product Sales

TobaccoTactics Resources

• Flavoured and Menthol Tobacco
• Menthol Cigarettes: Industry Interference in the EU and UK

TCRG Research

A growing menace: menthol and flavoured tobacco products in LMIC, M. Zatonski, K. Silver, S. Plummer, R. Hiscock, Tobacco Induced Diseases, 2022;20(April):39, doi:10.18332/tid/146366
STOP research summary (May 2022)

Marketing of flavour capsule cigarettes: a systematic review, C. Kyriakos, M. Zatonski, F. Filippidis, Tobacco Control, Published Online First: 18 January 2022, doi: 10.1136/tobaccocontrol-2021-057082[/ref]

Flavour capsule cigarette use and perceptions: a systematic review, C.N. Kyriakos, M.Z. Zatoński, F.T. Filippidis, Tobacco Control, Published Online First: 04 October 2021, doi: 10.1136/tobaccocontrol-2021-056837

For a comprehensive list of all TCRG publications, including research that evaluates the impact of public health policy, go to TCRG publications.

References

The post Flavoured and Menthol Tobacco in LMICs appeared first on TobaccoTactics.

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”.¹⁷¹ Some countries have developed their own definition of waterpipe tobacco smoking (WTS).¹⁷²

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.¹⁷³¹⁷⁴

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.^171174175176In this way waterpipe has spread beyond the Middle East and become integrated into the global tobacco market.¹⁷⁷ 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).^175176171

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.¹⁷⁸

This was the case until  2012, when Japan Tobacco International (JTI) acquired Egyptian company Al Nakhla.¹⁷⁹ At the time Al Nakhla was globally the largest company manufacturing waterpipe tobacco products.¹⁸⁰ However, even this was perceived as a strategy to enhance the sale of cigarettes.¹⁷⁸

In 2019, Philip Morris International (PMI) filed a patent ‘Shisha device for heating a substrate without combustion.’¹⁷⁸  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)¹⁸¹¹⁸²

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.¹⁷⁵

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.¹⁷¹

• 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.^175176171

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.¹⁸³. 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.¹⁸⁴  A study among , adults in Lebanon indicated that the introduction of novel tobacco flavours contributed to people initiating WTS and increased its use.¹⁸⁵ 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’.¹⁸⁶

• 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.¹⁸⁷

As with cigarettes and rolling tobacco the smoke of waterpipe is toxic and carcinogenic. One study identified 27 known or suspected carcinogens. ¹⁸⁸As a waterpipe is often shared, it is also a mode of transmission for communicable diseases, a particular concern during the COVID-19 pandemic.¹⁸⁹ 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.^171190191192

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.^175176171 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.”¹⁹³

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.¹⁸⁸¹⁹⁴

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.¹⁹⁵

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 ¹⁷⁶ 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.¹⁹⁶

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.¹⁹⁷ A study in Western Cape from 2013, reported higher figures: 40% current use, and 70% ever use.¹⁹⁸ 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.¹⁹⁹

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.²⁰⁰ In Canada, although cigarette smoking among young people had significantly decreased, waterpipe use increased by 2.6% among young people between 2006 and 2010.²⁰¹

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.²⁰² It also increased in multiple countries, with prevalence ranging from 9% to 15%.²⁰³

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.²⁰⁴ In England, data from 2013 indicated that for people aged 16-18 the level of waterpipe smoking was low, at 3%.²⁰⁵

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.²⁰⁶.

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.²⁰⁷²⁰⁸ 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.²⁰⁷

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.^175176171174

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”.²⁰⁹ 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.²¹⁰
• 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.²¹¹
• At COP7 in 2016, more detailed instructions were given to Parties, including to ban the use of flavourings in waterpipe tobacco products.²¹²
• 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.²¹³

The full list of articles covering waterpipe are listed in the Fact sheet: Waterpipe tobacco smoking & health.¹⁷¹

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. ²¹⁴

In 2018, the WTS knowledge hub submitted a report to the WHO FCTC COP8 that summarized Parties’ regulations concerning waterpipe.²¹⁵ This report was updated in 2022, and found that, of the 90 countries reviewed, over half (47) had policies relating to waterpipe.¹⁷² The majority of policies, nearly 45%, were in Europe and around 21% in EMR.¹⁷²

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.¹⁸⁹ In EMR alone, 17 countries banned waterpipe tobacco use in public places.²¹⁶

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.²¹⁷²¹⁸ 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.²¹⁹

The WTS market is still concentrated in the Middle East and Africa, followed by  Europe.²²⁰ Market analysis company Valuates estimated that as of 2022 the global WTS market was worth over US$ 800 million, forecast to nearly double by 2029.²²⁰

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.²²¹

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.²²² 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).²¹⁹ Products are promoted online by users via social media, rather than WT companies.²¹⁹  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.²²³

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.²¹⁹²²⁴

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.²¹⁹  WTS charcoal companies in particular published misleading information about charcoal being ‘100% natural’ and ‘free of chemicals’.²¹⁹

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.²²⁵

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.²²⁶

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.²¹⁹¹⁷¹.

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.²²⁷ The illicit products are from both unauthorized domestic production, and increasingly tobacco smuggled from other countries, reported to taste better than locally manufactured products.²²⁸

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.²²⁹

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. ²³⁰

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.²³¹

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.

Article 17 of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) encourages parties to promote sustainable alternatives to tobacco farming.²³⁶ There is a consensus that diversification programmes, designed for the local context, can improve farmers’ livelihoods.

Despite a global trend of decreasing tobacco consumption from 2000 to 2020,²³⁷ and an overall worldwide decline in tobacco leaf production during the same time period,²³⁸ tobacco remains a popular cash-crop choice for many farmers, especially in low- and middle- income countries (LMICs) where the vast majority of tobacco farming takes place.²³⁹²⁴⁰  The global fall in tobacco leaf production has been accompanied by a production shift from Europe and other high income countries, towards lower income countries like Malawi, Kenya, Uganda and Zambia^238241242

The tobacco industry portrays tobacco farming as economically advantageous for governments and especially for farmers. Other claims include that it helps improve resilience, empowers low-income populations and strengthens communities, while the industry also tends to minimise the risks of tobacco growing for health and the environment.^243244245

In reality, tobacco farming often leads to economic hardships, labour exploitation, environmental degradation, and health problems for farmers. Farmers often have less influence within the political process than non-tobacco growers in the same area.²⁴⁶

Image 1: Tobacco leaf drying (Source: Shutterstock)

The myth of economic prosperity

According to the tobacco industry, tobacco cultivation promises high rates of return for investing in tobacco crops and long-term benefits to smallholder farmers.^243244245

However, tobacco growing is often less profitable for farmers than other crops, and tobacco-growing families are poorer than comparable non-tobacco-growing households.²⁴¹²⁴⁷ In Lebanon, research has shown that small scale production is so unprofitable that it would not be possible without government subsidy.²⁴⁸

Evidence shows that the labour costs of growing tobacco are enormous, as much as double the labour needed to produce other similar crops. For example, tobacco is amongst the most labour-intensive crops in Kenya, requiring over 1,000 hours of unpaid labour to produce one acre of tobacco.²⁴⁹ The number of hours needed for tobacco growing stops families spending time attaining educational qualifications or developing skills that might lead to more lucrative livelihoods.

Tobacco growing also creates specific vulnerabilities for farmers:  they depend on tobacco companies for inputs and technologies, and are exposed to fluctuations in the price of tobacco leaf.²⁵⁰

In its reporting, the tobacco industry minimises the low rates of return on investment for tobacco growing and downplays the financial risks for the farmers. For example, BAT reported that in Kenya, tobacco farmers can either grow food for their families’ needs or have sufficient profits to purchase food.²⁴³ A 2020 study of tobacco farming in Kenya instead shows that most tobacco farmers are stuck in unprofitable ‘contract farming’ systems and 10-15% are food insecure.²⁴⁹

Contract farming

Most tobacco farmers work under a contract system with leaf buying-companies or directly with transnational tobacco companies like BAT.²⁴⁹²⁵¹

Under these systems, farmers receive inputs like plants, fertiliser and machinery at the start of the season from leaf-buying companies, without having to pay for these upfront. In return, they commit to selling their tobacco to the leaf merchant. However, leaf prices are dictated by the buying companies, who often set these very low or reduce them during the contract period. Leaf buyers often use tobacco grading, or the classification of leaf quality, to reduce the offer price, often in disagreement with farmers.^249252253 Leaf buying companies can also deduct unfairly high costs from the payment they offer farmers, to pay back the inputs they initially provided.²⁴⁹

Contract farming rarely produces the high returns promised by tobacco and leaf-buying companies. Instead, contract farmers remain stuck in ‘bonded labour’: debt cycles where they never earn enough to repay their debts.^249251253254 Contracted farmers often have to rely on the unpaid labour of family members and children in fields in order to meet contract requirements.²⁵¹

Farmers often understand that this contract system for tobacco farming is risky but agree to this work because they lack the credit to pursue other economic opportunities. Contract tobacco growing guarantees them the income, however low, that they need in order to pay for basic necessities like healthcare and education.²⁴¹

The COVID-19 pandemic and profitability

The COVID-19 pandemic worsened the struggle of farmers to find fair prices for their tobacco leaf. In Malawi, farmers reported receiving less than half of the expected rate for their tobacco leaf at auction.²⁵⁵ Fears that crowded auction floors and direct contact between growers and buyers would promote transmission of the virus prompted Zimbabwean authorities to delay the opening of the tobacco market selling season.²⁵⁶²⁵⁷ Once the markets did open, new regulations stated that individual farmers would not be allowed onto auction floors where they could observe buyers; tobacco association representatives would instead sell leaf on behalf of farmers.²⁵⁷

• For more information on the tobacco industry and COVID-19, see our page on COVID-19

The climate crisis and profitability

The climate crisis in tobacco-growing regions makes profits from tobacco growing more unreliable.

In Zimbabwe, shorter and more erratic rainy seasons decrease the quality and quantity of tobacco crops, especially for smallholder farmers who can’t afford irrigation systems and rely on rainfall instead.²⁵⁸

In the tobacco-growing region of Temanggung, Indonesia, the phenomenon of late tobacco harvesting seasons has become increasingly common. In this region, farmers have been losing income, as companies purchase tobacco leaf from other regions where harvesting happens earlier in the year.²⁵⁹

Farmers in tobacco growing regions that are heavily impacted by the climate crisis have been developing adaptation and mitigation strategies to maintain the profitability of their tobacco crops, such as irrigation systems and later harvesting. However, research indicates that “even with these adaptations tobacco and maize are riskier crops to grow than traditional grains.”²⁵⁸²⁶⁰ soil degradation,²⁶¹²⁶² biodiversity loss,²⁶³ the use of pesticides,²⁶⁴²⁶⁵ and adverse effects on farmers’ health.²⁶⁶ Despite this, tobacco companies use ESG rankings and accreditations to clean up their image.²⁶⁷

• For more information, see the page Tobacco and the Environment

Image 2: A farmer carrying a bundle of tobacco leaf (Source: Shutterstock)

Vulnerable communities

Together with the narrative of economic prosperity comes the myth that impoverished and vulnerable communities are empowered. Philip Morris International (PMI) published a report in April 2020, focusing on the empowerment of women for change in its supply chain. In this report, PMI argued that it works to “empower women to play an active role in improving the household economic condition but also in enhancing the overall wellbeing of their children and maintaining a safe work environment” on tobacco farms.²⁶⁸ However, a study in Zimbabwe concluded that women in households growing cash crops, in particular tobacco, were more likely to be disempowered.²⁶⁹ A study conducted in China, Tanzania and Kenya concluded that few women in tobacco growing households in Tanzania and Kenya had any financial decision-making power. Women also face particular harmful effects to their health while working on tobacco farms, including the risk of miscarriage while pregnant.²⁷⁰

All four transnational tobacco corporations present a strong and compelling narrative around tobacco farming: that it will improve livelihoods, strengthen communities, provide good working conditions and deliver financially stable futures for farmers.^271272273274 For example, Japan Tobacco International (JTI) states on its website that “Growers know they will receive meaningful support that not only leads to improved yields and profits, but that also help improve the social conditions and quality of life in their communities.”²⁷⁵

However, a WHO report on tobacco and the environment published in 2017 found that the long-term consequences include “increased food insecurity, frequent sustained farmers’ debt, illness and poverty among farmworkers, and widespread environmental damage”.²⁵² Tobacco farmers end up having to dedicate intensive labour hours to produce tobacco leaf, in inadequate working conditions, with low wages and unfair conditions that include child labour (see below).

• For more information on the tobacco industry narratives around farming see International Tobacco Growers Association

Health risks to farmers

Tobacco leaf production has many health risks, which are frequently underreported by the tobacco industry.

According to the World Health Organization, “each day, a tobacco worker who plants, cultivates and harvests tobacco may absorb as much nicotine as found in 50 cigarettes”.²⁴⁰ Nicotine poisoning, also known as green tobacco sickness, occurs as a result of exposure to wet tobacco leaves during tobacco cultivation. Children are more likely to develop green tobacco sickness, not only because they have a relatively smaller body size, but also because they have not yet built up the nicotine tolerance which is needed protect them from these side effects.²⁴³ Avoiding nicotine poisoning when working with tobacco plants is difficult, even when wearing protective equipment. BAT reported several cases of green tobacco sickness in its Brazilian farming operations, despite workers having worn protective equipment.²⁴³

Another risk resulting from tobacco farming is the exposure to agrochemicals, including pesticides. Researchers found that in Kenya, 26% of tobacco workers showed symptoms of pesticide poisoning;²⁷⁶ in Malaysia, this number was higher than a third.²⁷⁷ In Bangladesh, where weed killer is frequently used in tobacco fields, significant levels of chemicals were also detected in local water sources, killing fish and soil organisms needed to maintain soil health.²⁷⁸

The risk of exposure to agrochemicals is generally lower for tobacco farmers in high-income countries than in LMICs, where the regulation of chemicals tends to be weaker.²⁶¹ Dichlorodiphenyltrichloroethane (DDT) plus eleven other persistent organic pollutants used in agrochemicals are banned in high income countries, but not in some LMICs.²⁶¹²⁷⁹ Pesticides are often sold to tobacco farmers in LMICs without proper packaging or instructions.²⁶¹²⁷⁹ The health effects that derive from chronic exposure range from birth defects and tumours to blood disorders, neurological diseases and depression.²⁶¹²⁷⁹ Even tobacco workers who do not directly mix or spray chemicals, like harvesters, can be exposed to significant levels of toxins and are susceptible to pesticide poisoning.²⁵²

Child Labour

Child labour is a prevalent and long standing issue in the tobacco farming sector.²⁸⁰

Children involved in the growing stages of tobacco farming take part in labour-intensive activities,²⁸¹ which poses risks to their health,²⁸²²⁸³ and limits their access to education.²⁸⁴²⁸⁵

Children working in tobacco farms are also more vulnerable to the health risks than adults, including the impacts of absorbing nicotine.²⁸⁶

Many of the children working in tobacco fields in Kenya report handling fertilisers and chemicals, endangering their health.²⁴⁹²⁸⁶

Tobacco farming and the FCTC

The World Health Organization Framework Convention on Tobacco Control (WHO FCTC) is an international treaty that aims to reduce the demand and supply of tobacco.

It recognises that as countries and governments adopt measures to reduce the demand of tobacco products, they must also address the consequences of this demand reduction on tobacco farmers who rely on these crops for their livelihoods.²⁸⁷

Specifically, article 17 recognises the need to:

“promote economically viable alternatives to tobacco production as a way to prevent possible adverse social and economic impacts on populations whose livelihoods depend on tobacco production.”²³⁶

The tobacco industry argues that tobacco control policies threaten the economic benefits  that it claims tobacco growing brings to local farmers.²³⁶However, other crops can provide much more sustainable alternatives. In addition, demand reduction happens slowly, allowing farmers to diversify their crops gradually, reducing the economic impact.²³⁶

Parties to the WHO FCTC also have an obligation to:

“have due regard to the protection of the environment and the health of persons in relation to the environment in respect of tobacco cultivation and manufacture within their respective territories.” ²⁸⁷

• For more information see the page on Tobacco and the Environment

Corporate Social Responsibility and Environmental, Social and Governance

In response to increasing scrutiny over environmental degradation and the use of child labour in the tobacco supply chain, transnational tobacco companies have invested in Corporate Social Responsibility (CSR) initiatives which they describe to their shareholders in their Environmental, Social and Governance (ESG) reports.²⁶⁷

• For more information, see the pages on CSR: Child Labour, and the Eliminating Child Labour in Tobacco-Growing (ECLT) foundation

The tobacco industry has also been involved in CSR programmes supporting farming diversification in tobacco growing regions, despite the FCTC specifically recommending that “policies promoting economically sustainable alternative livelihoods should be protected from commercial and other vested interests of the tobacco industry”.²³⁶²⁸⁸

• See Greenwashing in Malawi and the Centre for Agricultural Transformation (CAT)

PMI’s ‘Agricultural Labour Practices’ (ALP) Programme

On 10 December 2020, PMI published an article seeking to celebrate the International Day of Human Rights by promoting its achievements around its Agricultural Labour Practices (ALP) program. This programme was created by PMI in 2011, seemingly aiming to end child labour and protect workers’ rights and livelihoods.²⁸⁹

According PMI’s ALP 2020 report, the key principles of the programme include “no child labor, no forced labor or human trafficking, fair treatment, safe working environment, fair income and work hours, freedom of association, and terms of employment”.²⁹⁰ However, the timeline below (Image 3) from the same report, shows how, despite the programme having run for 9 years, PMI continues to use child labour in its supply chain. The company has given itself a further 5 years to end the practice.²⁹⁰

Image 3: Timeline of the ‘Agricultural Labor Practices Program’ (Source: Philip Morris International, ALP program 2020 report)²⁹⁰

• For more information on PMI’s ALP programme, and how tobacco companies fail to properly measure or manage the effectiveness of this type of initiative, see CSR: Child Labour

TobaccoTactics Resources

• Greenwashing
• Tobacco and the Environment
• CSR: Child Labour
• Tobacco Supply Chain Database: addressing the supply side of the tobacco epidemic

Relevant Links

• TCRG blog Supplying the deadly tobacco industry
• WHO World No Tobacco Day 2023: Grow food, not tobacco includes a myth buster on Tobacco growing
• WHO report: “Tobacco and the environment”
• Tobacco Atlas

TCRG Research

For a comprehensive list of all TCRG publications, including TCRG research that evaluates the impact of public health policy, go to the Bath TCRG’s list of publications.

References

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