Abstract
Tobacco use still represents a major threat to global public health and this calls for extensive efforts to control tobacco products and advocate harm-reduction policies. Recent global trends of prevalence rates in smoking are promising, as trajectories show a decline in all World Health Organization regions. Yet, this decline varies significantly at the national level. Jordan, as a country in the Eastern Mediterranean Region, has been in a long battle against tobacco. Despite that, the country is found to have one of the highest prevalence rates of tobacco use in the region and the world. Many challenges slow down effective and successful anti-tobacco policy implementation in Jordan, most notably cultural influences on smoking and the interference of the tobacco industry in tobacco policy making. Decision makers in Jordan should consider strengthening of anti-tobacco measures to avoid a public health catastrophe if tobacco use keeps rising at the current pace.
Keywords
Introduction: a global lens on tobacco use
Tobacco smoking still represents a major threat to global public health and a main risk factor for a wide range of preventable illnesses. More than 8 million lives are lost every year due to tobacco use, of which 1.2 million deaths occur among non-smokers exposed to tobacco smoke (1,2). It is also important to stress that the majority of tobacco users and tobacco-related morbidity and mortality are found in low- and middle-income countries (1). Over the past decades, tobacco control has been a tough mission even in the 182 countries that are party to the Framework Convention on Tobacco Control (FCTC) (3).
Despite the immense and extensive efforts taken by the FCTC parties in tackling tobacco use, collecting essential data on usage patterns, advocating tobacco use reduction and cessation, strengthening tobacco harm-reduction policies, and promoting the MPOWER package (Monitor, Protect, Offer help, Warn, Enforce and Raise taxes), only 23 countries provide financially covered (full or partial) comprehensive cessation services (4), while many countries are still facing struggles in this mission.
While global trends in the prevalence of tobacco use are promising, and the age-standardized prevalence keeps declining in the six World Health Organization (WHO) regions, it is essential to mention that this reduction varies significantly at the country level (2,5). Based on the WHO global report on trends of tobacco use 2000–2025, a declining projection in the global prevalence of tobacco use among both sexes is noted. Nevertheless, the forecasted projection revealed a gap of (−1.8%) between the targeted rate (19.1%) and the projected rate (20.9%) in 2025 (2). According to the same report, the prevalence rates are expected to decline in the following trends (from rates in 2000 to projected rates in 2025): 18.5–11.2% in Africa, 30.8–15.4% in the Americas, 29.5–17.0% in the Eastern Mediterranean Region (EMR), 34.2–24.1% in the European region, 46.6–25.1% in South-East Asia, and 30.9–24.8% in West Pacific region (2).
Tobacco use in Jordan: a historical overview with an update on current status
The EMR consists of 22 countries with an overall population of 679 million inhabitants. The Hashemite Kingdom of Jordan, popularly known as Jordan, is one of the EMR countries, with a population of 10.8 million. Also, the World Bank classifies Jordan as an upper-middle-income country with a gross national income per capita of 4410 current US$ in 2019 (6). The battle against tobacco use in Jordan started back in the 1970s when the first tobacco control legislation was declared (7). In 2004, Jordan was the second country in the EMR to join the FCTC for more systematic and committed actions to control tobacco use in the country (7,8). Joining the FCTC had resulted in more serious steps in anti-tobacco regulations in Jordan (8), despite the lack of effective law enforcement. Table 1 outlines the evolution of main policies regarding tobacco control in Jordan.
Main outlines of anti-smoking policies in Jordan. a
A recent spotlight published in The Lancet points to a high rate of tobacco use in Jordan, with around 70% of men believed to be tobacco smokers (12). Also, tobacco smoking was cited as being part of Jordanian culture despite extensive efforts to control tobacco use. In a national survey carried out in 2019, 8 out of 10 Jordanian men were found to be regular smokers, with an average daily consumption of 23 cigarettes, surpassing the figures from Indonesia (13). Moreover, alarming data retrieved in 2021 from World Population Review (14) declared Jordan to be among the countries with the highest rates of smoking, ranked sixth globally with an overall prevalence of 40.45% (70.2% among men and 10.7% among women). Moreover, statistics on tobacco use are also alarming among teenagers in the country. A school-based survey of students aged between 11 and 18 years found that the rate of past-week waterpipe smoking was 30% (15). Another longitudinal study among school children found that 29.8% of 1454 students surveyed had started smoking combustible cigarettes by the tenth grade (16).
Despite high poverty and unemployment rates in Jordan, the country still tops its neighboring countries in rates of tobacco use (17,18). Availability, easy accessibility, and affordability of various forms of tobacco products that are being sold in the Jordanian market add additional burden to the effective control of tobacco use. For example, waterpipe or Argileh is served in most restaurants and cafes in the country, exposing a significant proportion of youths and young adults, who usually underestimate the danger of tobacco use, to a high risk of developing tobacco-related diseases due to direct use or indirect exposure to smoke. Previous figures on the prevalence of tobacco use in Jordan warn of an upcoming public health catastrophe if smoking rates keep rising at this rate.
Alongside tobacco products, the recent legislation of importation, distribution, and use of electronic cigarettes (E-cigarettes) in Jordan is expected to impose more challenges and burden on the anti-tobacco efforts (19,20). In the midst of the COVID-19 pandemic, the government announced licensing of 184 retail stores to display and sell E-cigarettes and their liquids as well as heated tobacco products (21). This seems contradictory to the national anti-smoking efforts, considering the potential of E-cigarettes as a gateway for initiating tobacco smoking among non-smoking youths due to their appealing flavors.
Major challenges of anti-tobacco efforts in Jordan
Despite the extensive history of tobacco control in Jordan, it seems that the responsible authorities have not been successful in providing effective implementation of anti-tobacco policies, as seen in the previously reported statistics. According to Heydari et al. (22), Jordan was amongst the countries that had low scores in implementing the MPOWER measures and ranked the 13th in the EMR (22). Also, total MPOWER scores in 2011, 2013, and 2015 were 26, 25, 19, respectively, which demonstrates a worrying decline in ideal implementation of MPOWER measures in Jordan (22).
No one would deny that tobacco use could be culturally influenced in Jordan, which imposes a difficult cultural norm to change; nevertheless, more stringent, and law-enforced measures should be implemented and monitored for a noticeable reduction in tobacco use. For example, despite the existence of anti-smoking regulations and warning signs, smoking in public transport and many public places is a normal sight in Jordan, and this explicitly reveals a severe deficiency in the enforcement of anti-smoking measures and weaknesses in the monitoring system.
Based on a recent report on the level of adherence and compliance to the WHO MPOWER package, some domains were not sufficiently advocated or implemented in Jordan (23). For example, regarding monitoring (M) of tobacco use and tobacco policies, Jordan has minimal policy adherence to having recent and representative smoking data for either adults or youth. Regarding protection and smoke-free environments (P), Jordan also has minimal adherence to policies of smoke-free areas and scored 3 out of 10 on this item. Regarding offering help and cessation programs (O), Jordan has a moderate-level policy implementation, although smoking cessation support is not widely available and a toll-free telephone quitline with a person to discuss cessation with callers is not available. Concerning health warnings on tobacco packages (W) and anti-tobacco mass media campaigns (W), Jordan has moderate-level policy implementation and complete policy implementation, respectively. For enforcement of advertising bans (E), Jordan has moderate-level policy implementation and scored 5 out of 10 in compliance with this item. And finally, regarding taxation (R), Jordan has complete policy implementation in this item (23).
Alongside the challenges in the ideal implementation of MPOWER strategies in Jordan, the interference of tobacco companies in tobacco policy development represents a major obstacle in the anti-tobacco mission. A worrying influence from the tobacco industry and its front groups is present in the process of tobacco policy making in Jordan (24,25). Moreover, Jordan scored 77 points in Global Tobacco Index and was ranked 31st among the surveyed 57 countries, representing a high level of influence and interference in tobacco policy-making by tobacco companies (26). In addition, lack of transparency in disclosing the interactions between the government and tobacco industry, absence of laws that exclude tobacco front groups during regulating tobacco products in Jordan, and the absence of regulations that prevent government officials and relatives from holding positions in tobacco industry, all are a major drawback in the Jordanian anti-tobacco mission (26).
Recommendations
In the current situation, it is wise to carry out nationwide campaigns to raise awareness about the dangers of tobacco use in the country. Utilizing social media platforms to spread anti-smoking messages is believed to be a cost-effective and time-efficient way to target Jordanian society with these messages. High school students and university students could be also reached through regular awareness lectures as part of university-based or high-school-based campaigns.
The Jordanian government and decision-makers should realize that the profits and economic rewards from tobacco sales have a price that is taken from people’s health and wealth. It is irrational to try implementing anti-tobacco measures and at the same time encourage the tobacco industry in the country. It should be noted that, without complete governmental jurisdiction and governance over tobacco policymaking in the country, it will be almost impossible to achieve an impactful policy implementation and tobacco harm reduction. Hence, the interference of the tobacco front groups in tobacco policy-making should be halted. All national anti-tobacco efforts should be strengthened and enforced effectively to lower the rates of tobacco use in order to achieve a healthier community and generation; thus, more ‘healthy’ economic revenues can be achieved than that from tobacco sales. More reliable actions should be effectively advocated to reverse the significant economic losses that result from tobacco-related morbidity and mortality. Looking at the current status of tobacco use in the country, the taxation system on tobacco products should be also reviewed and adjusted regularly to achieve a continuous and stepwise annual rise aiming at reducing tobacco affordability. The current situation of tobacco use in Jordan calls for immediate and well-executed action in collaboration between the government and non-state anti-tobacco actors to avoid further negative impacts on health and the economy that may result from a tobacco epidemic in the country. Lastly, anti-tobacco measures should also consider the complexity and roots of tobacco use in the community, considering socio-economic determinants, gender-influenced tobacco use, adolescents at high risk of adopting unhealthy behaviors due to peer pressure, macro-and micro-socioeconomic influences, and a balance between legal frameworks and effective implementation of anti-tobacco policies (27).
Footnotes
Declaration of conflicting interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author received no financial support for the research, authorship, and/or publication of this article.
