Middle East Journal of Family Medicine

Mohamed Ghaith AL-Kuwari, MBBS, ABCM, FPHM
Senior Specialist in Public Health Medicine (Health Promotion)
Secretary General to Qatar Medical Society

Correspondence to:
Mohamed Ghaith Al-Kuwari
Senior Specialist in Public Health Medicine
Primary Care
Hamad Medical Corporation
Doha- Qatar
P O Box 5054
Tel: +974- 4473 226
Fax: +974- 4473 223
Mobile: +974- 551 4962
e-mail: drmgalkuwari@hotmail.com

ABSTRACT

The import and usage of tobacco products are progressively increasing in Middle East. National health data in Qatar revealed that tobacco use is a major public health problem with prevalence of 37% and imposes a huge burden on health care services with its associated mortality and morbidity especially coronary heart disease and cancer. The aim of this paper is to describe Qatar's approach to tobacco control, which is based on three strategies: legislative measures raise public awareness, and providing smoking cessation services for smokers. Since 1996, Qatar is taking a leading role in imposing anti-smoking legislative measures in the Arab world and by issuing the first comprehensive tobacco control law in the country, which includes smoking bans and increased taxes on tobacco products. In addition to establishing smoking cessation clinics to help smokers to quit, different sectors are supporting a number of tobacco awareness campaigns with the main focus on preventing youngsters becoming smokers. The tobacco control strategy in Qatar needs to be modified to tackle a number of challenges that have appeared recently.

Key words: Tobacco use; Tobacco Control; Smoking; Qatar.

It has been known for many decades that tobacco is the leading preventable cause of ill health and premature death in the world. It causes 1 in 10 deaths among adults and about 4 million premature deaths worldwide^1,2.

Available data in the Middle East indicate a considerable and steady increase in tobacco consumption over the past three decades. Data also demonstrates high rates of smoking in these countries, especially among men where smoking prevalence rates among adult males increased up to 40% in some countries. Moreover, imports and manufacture of cigarettes are progressively increasing in this region^3-5.

While the prevalence of smoking in the Arab countries of the Persian Gulf is 30-50%, national health data in Qatar, the second smallest country in the Persian Gulf with a total population of more than 724,125, reported that the prevalence of smoking is 37% among males and 0.6 % among females according to the Gulf Family Health Survey (GFHS) in 1999. On the other hand smoking is increasing among all youths (15-18 years old) from 13% in 1998 to 18% in 2001 according to the Global Youth Tobacco Survey (GYTS)^6-8.

Smoking-related diseases in Qatar are the most prevalent diseases. While Coronary Heart Diseases (CHD) is ranked as the leading cause of death among adults over 40 years-old^9,10, Qatar has the second highest lung cancer age-standardized incidence rate among Arab countries in the Persian Gulf after Bahrain with a rate of (18.5 for males, 5.5 for females) 100,000 person-years¹¹.

There is no accurate data regarding the annual imported tobacco by Qatar but the best available data showed that it is more than 1,110 tons. In the last ten years the imported tobacco for consumption was around US$ 15 million annually⁸.

This paper aims to describe the current public health strategies and challenges of tobacco control in Qatar.

Tobacco control in Qatar incorporates the international strategies recommended by the World Health Organization (WHO) and Regional plan of Arab countries in the Persian Gulf. Currently, tobacco control approaches in Qatar are based on three strategies: legislative measures, increase of public awareness, and providing smoking cessation services for smokers.

Qatar took a leading role in imposing tobacco control legislative measures in the Arab world. In 1996, the Ministry of Health has banned smoking in its premises, which includes all offices, primary care clinics, and hospitals. In 1999 another law has been issued to increase the custom duties on imported tobacco products.

The first comprehensive law concerning the control of tobacco and its derivates in Qatar has been put into force in 2002. The Law number 20 of 2002 encompasses a range of legislative measures starting from smoking bans in enclosed public places, banning advertising for tobacco products, prohibition of selling tobacco products to minors, and other measures (as shown in Table-1).

The Health authorities implement the law by officials with judicial powers to report any incidence of violations of the law and imposing the fines. The law imposes a fine which ranges from 200-500 Qatari Riyals (US $ 54.8- 137) against anyone who breaches the law by smoking in enclosed public places. Whereas the law punushes anyone who sells any tobacco products to minors with six months prison and/or a fine of 5,000 Qatari Riyals (US $ 1,370).

In June 2003, Qatar has signed The Framework Convention on Tobacco Control (FCTC), which is the world's first ever public health treaty which embraces all elements of a comprehensive tobacco control agenda. In July 2004 the FCTC has been ratified in the country.

In Qatar, smoking cessation services have been provided free of charge since 1999. These services include providing personal counseling, monitoring carbon monoxide levels, prescribing nicotine replacement therapy (NRT) and Bupropion by public health medicine physicians who are trained in smoking cessation counseling.

Till now there are only two smoking cessation clinics in Doha and Al-Khor (the second largest city). It is estimated that more than 700 smokers utilize the services annually and the quit rate reaches 38%.¹² Unfortunately both clinics are hospital-based and there is no single primary care or community-based clinic that can provide good accessibility to quit smoking.

In the last ten years a number of anti-smoking activities have been implemented in Qatar aiming to increase the awareness of the public about the adverse effects of both smoking and passive smoking. The main efforts have been directed to tackle smoking among school students through the school health education program provided by the National Health Authority of Qatar (NHA-Qatar) and Ministry of Education. These activities include educational sessions on harmful effects of smoking, developing personal skills to deal with peer pressure, and training of school's social workers as smoking cessation advisors. Also smoking has been used as a subject for "Draw in Health", which is a school students' competition aimed to design a health education poster.

Another program focused on promoting quitting of smoking among smokers through the international smoking cessation competition "Quit & Win". This competition was supported financially by one of the Islamic Charity Organizations.

In addition to the efforts of the NHA and Ministry of Education, new partners have joined the campaign to tackle smoking habits. Some of these partners are governmental like the Ministry of Islamic Affairs, petroleum companies, and gas companies. While other partners were non-governmental organizations like The Qatari Society of Cancer Control, and Sport clubs.

Lately community mobilization has been used to control smoking in one of the Qatari cities, Wakrah. "Smoke Free Wakrah" is a community-base initiative which aims to prevent adolescents from being new smokers through peer education, restricting selling tobacco products near places visited by youngsters, such as schools, parks, and sport clubs. Advocacy has been used in this initiative in different areas, like mass media, mosques, and street marches. Smoke Free Wakrah was initiated by social workers in all schools of Wakrah, including girls' schools and supported by a large number of local community leaders and businessmen.

Tobacco control in Qatar faces a number of challenges that are considered as barriers for its success. Tobacco control legislation is regarded as a major strategy for tobacco control in Qatar.

However it has some crucial limitations like the low price of tobacco products in Qatar, compared to other countries even after a 10% increase in price. For example in 2003 a packet of 20 sticks costs US $ 1.37- 1.92, which is still considered as a very cheap price in a rich country like Qatar. It is also apparent that there is poor level of compliance with smoking bans in enclosed commercial buildings like malls, and companys' offices compared to the governmental buildings and worksites due to the severe shortage of officials with judicial powers to check violations of the law, all days of the week.

Another challenge in tobacco control is the other forms of tobacco that appeared recently such as Water Pipes and chewing tobacco. The number of people getting addicted to smoking and "sheesha" (Water Pipe) is alarmingly on the rise in Qatar, especially among women, despite the law introduced six years ago on the control of tobacco and its derivatives. The increasing numbers of sheesha cafes showed that the tobacco control law doesn't cover the restriction of this type of smoking.

On the other hand using chewing tobacco has never been known in Qatar till migrants from the Indian sub-continent, who came to Qatar for work, brought it in the 1980s. Now using chewing tobacco is increasing among adolescents and youths in educational institutes and recreation centers as most of them thought wrongly that it is a harmless tobacco.

Lack of updated information regarding prevalence of different types of tobacco and the amount of tobacco used is a major defect in the tobacco control strategy in Qatar. Such information on tobacco use and economics is crucial for measuring the impact of public health policies particularly in primary care clinics.

Lastly most of the physicians, nurses, and health educators in Qatar are not trained in delivering smoking cessation counselling. This point affects the accessibility of many smokers who would like to quit, to smoking cessation services.

Tobacco use remains a major public health problem in Qatar and imposes a huge burden on health care services with its associated morbidity and mortality, although Qatar has taken a number of actions in order to tackle tobacco-related health problems. However still there is need to strengthen theses actions through a comprehensive tobacco control plan, which should include more inter-sectorial cooperation in implementing health education campaigns, the new rising smoking habits like water pipes and chewing tobacco. Besides the tobacco control law should be modified to cover other types of tobacco products and to increase their prices. Also smoking cessation services should be provided through a network of primary care- based or workplace smoking cessation clinics. Lastly more research about the effectiveness of these measures is needed.