Effects of meeting MPOWER requirements on smoking rates and smoking attributable deaths: Iraq

TunisiaEffects of meeting MPOWER requirements on smoking rates and smoking-attributable deaths Iraq This factsheet presents estimates of the effect of implementing MPOWER policies consistent with the WHO Framework Convention on Tobacco Control (WHO FCTC). The estimates are based on the Abridged SimSmoke model (1). WHO-EM/TFI/171/E Smoking prevalence Iraq is a middle-income country with a population of more than 30 million in 2011 (2), of which 70% live in urban areas and 20% is employed in agriculture (3). Based on the Iraq Family Health Survey (IFHS) conducted in 2006–2007, smoking prevalence (ages 12 and above) is 26.5% for males and 2.9% for females (4). A comparison of the IFHS results with the 2006 STEPwise survey for comparable age groups (25–64) found the rates were similar for males, but about 30% smaller for females (5). Abridged SimSmoke adjusted the IFHS estimate to reflect ages 18 and above to obtain a smoking prevalence of 33.0% for men and 3.5% for women. Tobacco control policies Protect people from tobacco smoke Based on the 2013 WHO report on the global tobacco epidemic (6), which includes data from 2012, Iraq had smoke- free legislation covering public transport, but none covering other public places. The compliance score was 4 out of 10, which was no change from previous years. Smoke-free policies were at the lowest level. Offer help to quit tobacco use In 2012, there was no toll-free quit line with a live person to discuss cessation available in Iraq. Nicotine replacement therapy could be purchased in a pharmacy without a prescription, but was not cost-covered. Bupropion and varenicline were not legally sold. Smoking cessation support was not available in health clinics or other primary care facilities, offices of a health professional, in the community, or in other places. Cessation programmes were at the lowest level in 2012. Warn about the dangers of tobacco In 2012, Iraq had a law mandating that health warnings appear on tobacco packages, but size was not specified and warnings were not rotating. Warnings were not required to have graphic images, but regulations are pending. Health warnings were considered to be at the lowest level. Iraq did not have any national anti-tobacco mass media campaigns in 2011–2012. There was a national agency/technical unit for tobacco control, but no full-time staff, in 2011. Enforce bans on tobacco advertising, promotion and sponsorship In 2012, Iraq had bans on direct tobacco advertising on national/international television and radio, local/international magazines and newspapers, and billboards, but there were no bans on point-of-sale or internet advertising. The compliance score for direct advertising bans was 7 out of 10. For indirect advertising, there were bans on the appearance of tobacco brands or products on television or in movies. However, there were no bans on the free distribution of tobacco products or sponsored events. The compliance score for indirect advertising bans was 5 out of 10. Marketing restrictions were considered between the second and third highest of 4 levels in 2012. Raise taxes on tobacco WHO’s comparable estimate for the price of a pack of 20 cigarettes of the most sold brand was 750.00 Iraqi dinars for 2008 and 500.00 Iraqi dinars for 2012. WHO’s comparable estimate for taxes as a percentage of retail price was 2.8% for 2008 and 4% for 2012; all taxes were import duties. Iraq Key findings The Abridged SimSmoke model for Iraq estimates more than 3.3 million smokers (3 million men and 320 000 women) in 2010, and projects more than 1.6 million premature deaths of smokers (1.5 million men and 160 000 women) alive in that year. • Increasing cigarette excise taxes to 75% of the retail price would prevent much youth smoking and reduce smoking prevalence by 15.9% in 5 years, increasing to 31.7% in 40 years, and ultimately avert more than 526 000 premature deaths. • Strong enforcement of comprehensive smoke-free laws is predicted to reduce smoking prevalence by 11% in 5 years, increasing to 14% in 40 years, and avert 230 000 premature deaths. • A well-publicized and comprehensive cessation policy can reduce smoking prevalence by 4.5% within 5 years, increasing to 11% in 40 years, and avert mare than 185 000 premature deaths. • Strong health warnings can reduce smoking prevalence by 6% within 5 years, increasing to 12% in 40 years, and prevent more than 199 000 premature deaths. • A high-level mass media campaign is projected to reduce smoking prevalence by 6.5% in 5 years, increasing to 8% within 40 years, and avert nearly 130 000 premature deaths. • A comprehensive marketing ban with enforcement is projected to reduce smoking prevalence by 7% in 5 years, increasing to 9% within 40 years, and avert nearly 146 000 premature deaths. Implementing the stronger set of policies suggested above, in line with the WHO FCTC, could reduce smoking prevalence by 37% in 5 years, 48% in 20 years, and increasing to 57% within 40 years. More than 934 000 premature deaths could be averted. The Abridged SimSmoke model incorporates synergies in implementing multiple policies. A large tax increase accompanied by strong smoke-free laws, health warnings, comprehensive marketing restrictions, a comprehensive cessation programme and a mass media campaign would reduce smoking prevalence by about 48% by 2025, thus meeting the global target. Limitations Abridged SimSmoke has been developed based on an extensively validated simulation model, providing support for the estimates given above. However, the model has certain limitations. • It does not consider shisha (waterpipe) and smokeless tobacco use. If tax increases and other policies are only directed at cigarettes, there may be a substitution to other forms of tobacco, which would offset some of the health gains from reduced smoking. If policies are also targeted toward the use of non-cigarette products, then substitution to these products may be reduced. • Projections for Iraq are based on smoking prevalence data from 2007 and population data from 2010. The model does not consider any additional initiation or cessation that would have occurred after that date in the absence of policies. • Cigarette taxes in Iraq currently only include a 4% import duty. Increasing taxes to 75% of the retail price would result in an exceptionally large price increase, and potentially lead to smuggling. Estimates based on such large price increases are beyond those considered in previous studies, and therefore the estimated effects should be viewed as less certain than those of the other policies. • As a middle-income country, the effects of reductions in tobacco use on smoking-attributable deaths may be lower than projected for Iraq, due to higher background health risks and lower smoking intensity and duration. Using the relative risks for low-income countries, the number of deaths (when the policies are implemented in combination) of those alive today is still more than 1 million and the number of lives saved is still nearly 650 000. References 1. Levy DT, Fouad H, Levy J, Dragomir AD, El Awa F. Application of the Abridged SimSmoke model to four Eastern Mediterranean countries. Tob Control. 2016;25(4):413–21. doi:10.1136/ tobaccocontrol-2015-052334 (http://tobaccocontrol.bmj.com/content/25/4/413, accessed 24 April 2018). 2. World population prospects: the 2015 revision. New York: Department of Economic and Social Affairs, Population Division; 2015. 3. World Factbook 2015. Washington DC: Central Intelligence Agency; 2015 (https://www.cia.gov/library/ publications/the-world-factbook/, accessed 3 September 2015). 4. Iraq Family Health Survey Report: (IFHS) 2006–2007. Baghdad: Ministry of Health, Ministry of Planning and Development Cooperation, World Health Organization; 2007 (http://www.who.int/mediacentre/news/ releases/2008/pr02/2008_iraq_family_health_survey_report.pdf, accessed 24 April 2018). 5. Iraq STEPS survey 2006. Geneva: World Health Organization; 2006 (http://www.who.int/ncds/ surveillance/steps/Iraq_2006_STEPS_FactSheet.pdf, accessed 24 April 2018). 6. WHO report on the global tobacco epidemic, 2013: enforcing bans on tobacco advertising, promotion and sponsorship. Geneva: World Health Organization; 2013 (http://apps.who.int/iris/ bitstream/10665/85380/1/9789241505871_eng.pdf?ua=1, accessed 3 September 2015). © World Health Organization 2018 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).