Tobacco in the Arab world: old and new epidemics amidst policy paralysis

Abstract

The Arab world is comprised of 22 countries with a combined population of ∼360 million. The region is still at the initial stages of the tobacco epidemic, where it is expected to witness an increase in smoking levels and mounting tobacco-related morbidity and mortality in the future. Still, the bleak outlook of the tobacco epidemic in the Arab world continues to be faced with complacency in the form of underutilization of surveillance systems to monitor the tobacco epidemic and prioritize action, and failure to implement and enforce effective policies to curb the tobacco epidemic. Understandably, the focus on the Arab world carries the risk of trying to generalize to such a diverse group of countries at different level of economic and political development. Yet, tobacco control in the Arab world faces some shared patterns and common challenges that need to be addressed to advance its cause in this region. In addition, forces that promote tobacco use, such as the tobacco industry, and trends in tobacco use, such as the emerging waterpipe epidemic tend to coalesce around some shared cultural and socio-political features of this region. Generally, available data from Arab countries point at three major trends in the tobacco epidemic: (1) high prevalence of cigarette smoking among Arab men compared with women; (2) the re-emergence of waterpipe (also known as hookah, narghile, shisha, arghile) smoking as a major tobacco use method, especially among youth and (3) the failure of policy to provide an adequate response to the tobacco epidemic. In this review, we will discuss these trends, factors contributing to them, and the way forward for tobacco control in this unstable region.

Keywords: Arab world; hookah; policy; tobacco industry; waterpipe.

Figure 1

Map of the 22 member states of the Arab league in their order of joining (Maziak 2009).

Figure 2

Age-standardized estimated prevalence of current cigarette smoking among men and women (15+ years) for selected Arab countries, 2009 (WHO 2009a).

Figure 3

Waterpipe picture (left) and schematic showing main parts (right) (Maziak 2011).

Figure 4

Current cigarette vs waterpipe smoking among 13–15 year olds in several Arab countries according to GYTS or surveys of comparable methods (Al-Mulla et al. 2008; Jasim et al. 2009; WHO 2010; Mzayek et al. 2012). *Based on a study in Baghdad city alone. †The estimates for ‘other’ tobacco were mainly for waterpipe. ^§Based on a study in Irbid city (Jordan).

Figure 5

Mean (±SEM) for plasma nicotine and COHb. Filled symbols indicate a significant difference relative to the pre-smoking, and * indicate a significant difference between sessions (Cobb et al. 2011). SEM = Standard Error of Mean.

Figure 6

Progression to current cigarette smoking among waterpipe smokers vs non-smokers at baseline. *P < 0.05, **P < 0.01 (Mzayek et al. 2012).