Policy Analysis Paper: Protect Public Health from Smoking Dangers Policy

(	Jawad Obaidi Correspondence: Jawad Obaidi MSN,RN Email: jobaidi@yahoo.com

Introduction As in other world countries, Tobacco smoking continues to be the leading cause of preventable death in Jordan (WHO, 2011). Jordan has a series of smoking control policies that have been established since 1971. However, apparently there are many factors that prevent the actual implementation of smoking control policies in Jordan. Thus, the purpose of this paper is to review the smoking control policies applied in Jordan, to demonstrate the efforts that have been spent at the national and international level to enforce these policies; to discuss the major factors that prevents the actual implementation of the smoking control policies; to assess and analyze and protect public health from smoking dangers policy in Jordan in regard to administrative ease, cost and benefit, effectiveness, equity, legality and political acceptability. In addition, to find out recommended alternatives for the policy weaknesses, finally, to propose solutions that may enforce smoking control policies to protect Jordanian health from the risk of tobacco smoking.

Tobacco smoking in the world
Tobacco smoking is still the leading cause of preventable death across the world (WHO, 2011). Each cigarette contains more than 4,000 different toxic chemicals which can damage the human body (WHO, 2011). Thus, tobacco smoking causes approximately 25 different kinds of diseases that may affect the heart, the lung, the brain as well other body organs (WHO, 2011). For example, cigarette smoking is a major risk factor for many fatal diseases such as coronary heart diseases, cerebral vascular accident, lung cancer, and chronic obstructive pulmonary disease (WHO, 2011).

Nearly more than one billion of the world's population is currently smokers; 80% of them live in low and middle income countries (WHO, 2011). Every year, approximately 6 million people die from diseases directly related to tobacco smoking of which more than 60,000 are people exposed to second hand smoke (WHO, 2011). More millions of people are affected by the non-fatal health consequences of tobacco smoking (WHO, 2011). Deaths from tobacco smoking are estimated to rise to more than 8 million per year by 2030; 80% of those deaths will occur in the developing countries (WHO, 2011).

Tobacco smoking in Jordan
Jordan is a developing country with a population of 6.35 million (Census Bureau of Jordan, 2012). Tobacco smoking in Jordan has become a growing national problem (Ma'ayeh, 2003). For example, in 2007 the statistics indicate that tobacco smoking is a very common habit among Jordanian adults. The prevalence of current smokers was 28% of the total population; approximately 50% of men report smoking compared with 5% of women (Belbeisi, Al Nsour, Batieha, Brown, & Walke, 2009). The statistics show that men aged 25-35 had the highest prevalence of tobacco smoking (63%). However, women aged 18-28 had the lowest prevalence of tobacco smoking (<1%) (Belbeisi et al, 2009). The prevalence of women smoking is relatively small and may be because women smoking is still a stigma in Jordanian culture.

Problem
Tobacco smoking is also a serious problem among Jordanian youths. The percentage of tobacco smoking among youths was 18% in 1999, 13% in 2004, and 16% in 2007, respectively (as cited by Belbeisi et al, 2009). Young males have greater prevalence of smoking compared with young females. For instance, nearly 20% of young males reported smoking compared with 7-10% of young females. However, nearly 35% of young males reported current use of another form of tobacco smoking such as Argela (water seal smoking tool) compared with 17% of young females (Belbeisi et al, 2009). High prevalence of Argela smoking among youths exists because many of them believe that Argela smoking does not have the same addiction and toxicity affects as tobacco smoking.

There is evidence that the smoking-related diseases have increasingly affected Jordanians' health. For example, during 2009, chronic diseases were responsible for more than 50% of deaths in Jordan (Jordan Ministry of Health, 2009). Death from stroke and heart diseases accounted for nearly 35% of all deaths. Malignant neoplasms accounted for nearly 13% of deaths, with lung cancer being the first cause of cancer deaths (Jordan Ministry of Health, 2009). With 223 lung cancer cases, 185 patients were smokers (Jordan Ministry of Health, 2009). Thus, any effort to prevent tobacco smoking will reduce the prevalence of the most chronic diseases that strike Jordanian health.

Besides the health burden of smoking in Jordan, Jordan spends approximately 500 million Jordanian dinars annually on tobacco products (Experts Tackle Religious, 2002). Statistics show that spending on tobacco smoking in Jordan rose from 352.3 million Jordanian Dinar (JD) in 2008 to 480 million in 2010 (Experts Tackle Religious, 2002). According to the Ministry of Health the indirect cost of tobacco smoking, in terms of health care for tobacco-related diseases, today stands at 500 million JD. (Note that 1 Jordanian dinars equals 1.42 US dollars).
Overall, two major tangible problems regarding tobacco smoking were found in Jordan. First, tobacco smoking is accessible to everybody. For example, cigarettes are available at an affordable price (around 2 dollars for a packet); most markets buy cigarettes as primary goods. The second problem is that tobacco smoking is a very common phenomenon in public places. People in Jordan smoke almost everywhere without regard to the warning signs. Thus, it is urgent to revise the current smoking control policies in Jordan and to investigate why the current health policies don't prevent the spread of tobacco smoking.

MOH Protect Public Health from Smoking Dangerous Policy Description

Rule 52 -
The words and phrases following wherever used in this chapter shall have the meanings assigned to them below unless the context indicates otherwise:

Tobacco products: products that consist, in whole or in part, of the leaf tobacco as raw material which are manufactured for use.

Whether smoking or absorbed sucking, chewing or inhaled.

Location: hospitals, health centers, schools, cinemas, theaters, public libraries and museums,
and government buildings, public and non-governmental media passenger arrivals and departure lounges at airports, and indoor stadiums, lecture halls and any other place the Minister decides to consider a public place to publish its decision in the Official Gazette.

Rule 53 -
A - prohibits any smoking of tobacco products in public places; it may be a decision of the Minister upon the recommendation of the Director health competent locates particular where smoking is permitted in the public place subject to public health and safety, the announcement of this place clearly in a prominent place and in Arabic.
B - Notwithstanding the provisions of paragraph (a) of this Rule, prohibits smoking in nurseries and kindergartens in the public and private sectors, and holds the relevant departments in collaboration with the ministry to set rules to implement the ban.
C - is committed to being responsible for the development of public space for the panel clearly marked with the words (no smoking) and the reference function
in prominent places, and make the necessary arrangements to monitor compliance.
Rule 54 -
No person may or public or private entity, including the print media, display or publish an announcement for the purposes of any advertising of tobacco products or distribution of any publication or tools or materials to publicize or advertise its products.

Rule 55 -
Prohibits any person from the following: -
A - the sale of tobacco products to those under the age of eighteen years.
B - retail sale of cigarettes.
C - making, importing, distributing or selling sympathomimetic tobacco products, including candy, cakes, games and tools manufacturer resembling any of tobacco products.
D - machines to sell tobacco products.
E - view any of the tobacco products except in accordance with a regulation issued for this purpose.

Rule 56 -
Each of producing or importing or marketed within the territory of the Kingdom regardless of tobacco products to put in a conspicuous place on the cans or packages or containers which they marketed tobacco products, shape or phrase or both determined by the specification Jordanian standard or by a decision issued by the Minister for this purpose.

Policy Evaluation
Clear policy goals written simply for readers of all educational levels, were selected for public places in schools and universities, classrooms and enclosed halls, hospitals and public health centers and private facilities.

The types of smoking policy and tactics include full cigar, Argela and even gum method.
Having identified special places; the minister decided to leave more room to expand the smoking ban for selected ages, who may buy cigarettes; the legal age is 18 years old and above and prevents selling or work in the area of smoking and prevents advertisements or ads that contribute to the dissemination of smoking and compels public institutions and relating to the Status of ads ban smoking.

Prevent the importation of any products which resemble any means of smoking and prevent retailing so as not to be within the reach of children and prevent cigarette vending machines.
Phrases should be placed and developed by the Jordan Institution for Standards and Metrology on anything imported or manufactured in Jordan outlining smoking is harmful to health and a picture of lung cancer.

Responsibilities were identified in the policy that any manager or officer of a public or private institution is an advocate of law enforcement within the foundation of all types and to place advertisements to prevent smoking and applied to employees and beneficiaries of the service within the institution.

The application of this policy has faced resistance from the owners of the restaurants and the coffee shops in Amman, Irbed, as well other Jordanian cities because Argela smoking is considered a basic service that is provided in these kinds of places in Jordan.

In June 2009, the law banning smoking in public places was expanded to involve banning smoking inside fast-food cafeterias; penalties were established in this section in a more formative way compared with the previous legislations. Besides that, the updated legislation provided clear mechanisms for supervision and monitoring of the smoking ban law.

Strengths
The policy is very important, because smoking has many harms on human health and it is an important step to reduce the diseases that may be caused by smoking, for the benefit of the citizens, and it even helps to avoid serious diseases such as lung cancer, Asthma, COPD, and heart disease. And it is devoted to preventing it in crowded and closed places, which is generally considered wherever humans are as visitors, employers, and customers.

Identified preventive measures to prevent ads and anything that could lead to the spread of smoking were posters to ban smoking in any enclosed or crowded space, prevent sale of all kinds of smoke for children below the age of eighteen which is the legal age and placing of sanctions on violating this policy.

Hired staff supervise this policy by doing the rounds of cafes and public places. The Ministry of Health employed 180 smoking ban officers to supervise restaurants, coffee shops, and any other shops that violate smoking in public places laws. For example, in March 2012, 12 penalties and 15 warnings were issued to many restaurants and coffee shops in Amman within two months. Besides that, smoking was prohibited among the staff of health care facilities. Ministry staff who smoked in health facilities were penalized through reductions in wages. At the international airport, where smoking is now prohibited with the exception of designated smoking areas, local officers for monitoring adherence were also assigned.

Weaknesses
Although there are well regulated smoking control policies in Jordan, as well as, the other national and international efforts that have been spent to enforce these policies, there are many still challenges that may prevent the actual implementation of these policies in Jordan.
The first challenge is that the tobacco companies with their strong financial and political influence are still running inside Jordan. And because planting tobacco is banned inside Jordan the tobacco companies import tobacco from outside the country. There are four tobacco industries still active in Jordan beside the cigarettes thatare imported from other countries.
Another barrier is the widespread tobacco marketing. Annually, tobacco companies spend millions of dollars to market the tobacco attractively. Through offering of cash prizes and a variety of gifts such as T-shirts, sport bags, and watches. Many markets and malls still place tobacco posters in front of their shops and because the fine imposed is relatively low and not strictly imposed. While advertising of tobacco smoking is forbidden in national TV and Radio Broadcasts by the Jordanian government, the government still has limited control over the cross-border advertisement on the Internet and other Arab satellite stations.

Another challenge is the lax enforcement of anti-smoking regulation. According to the public health law people who violate the public smoking law are subjected to fines between 25 to 500 JD which is relatively low. Although the MOH uses 180 smoking control officers to monitor smoking in the public places as well as monitoring shops from advertising tobacco smoking or selling the tobacco to juveniles, most of the officers are conducting their work in Amman and only a few of them work in other Jordanian cities.

The widespread attitude in Jordan is that smokers have the right to smoke indoors and cultural norms indicate that hosts are reluctant to ask smokers to put out their cigarettes, in fear of being impolite. Another problem in discouraging smokers by enforcing the law lies with health care providers and other people in Authority; it is not uncommon to see government officials setting a bad example by smoking in public and on camera during a televised indoor meeting.

The final, and may be one of the most important barriers that prevent anti-smoking legislation being put into action is due to the financial restrictions. The Jordanian government does not specify any budget to enforce tobacco control laws the same as other health laws. So the only financial source was coming from international organizations such as WHO and UNICEF.



Suggested Alternatives
After evaluating the policy to ban smoking in Jordan, and after focusing on generality and weaknesses in policy, there are several alternatives and additions that must be taken into account and that is to quit smoking. We must provide governmental clinics for smoking cessation and drugs like alternative nicotine replacement therapy and treatment of smoking addiction as in substance addiction.

To prevent home smoking by providing educational programs for parent smokers because of the significant impact on the behavior of youths in the future and whether they are going to smoke; much evidence suggests that policies related to youth access, in particular strong restrictions, are likely to play an important role in youth smoking behavior (Chaloupka and Pacula, 1998).

Increase awareness of the culture among health workers, academics, about smoking and their impact on the public attitude by increasing the penalty on them.

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Conclusion with Recommendations
It is clearly stated from the previous review that the major problem of smoking control policies in Jordan is not at the level of legislations but at the level of implementation. The laws were already issued and developed since 1971 and 1977. And all other laws that were issued later are only updating for the same legislations over time. However, the mechanisms of implementing those legislations are not sufficient to prevent the spread of tobacco smoking. For example, the law of banning smoking in public places did not prevent the hundreds of restaurants and coffee shops from serving tobacco smoking inside and outside the shops. Because employing 180 health officers centered at Amman to monitor shops is not enough to cover other Jordanian cities. Besides that, adequate resources should be provided for anti-smoking educational programs to ensure that these kinds of projects become more accessible to all Jordanians. Media also must be used more extensively to campaign for smoking ban policies. For example, the media must focus on the adolescents because they are more likely to be influenced by advertisement. Overall, in Jordan we need to increase our efforts and show serious commitment to enforcing tobacco control policies. Unfortunately, up to this moment, the mechanism of implementing the tobacco control policies is at the legislative bureau and introducing legislation without enforcement is not enough to fight the growing threat of tobacco smoking.

References
- Belbeisi A, Al Nsour M, Batieha A, Brown DW, Walke HT (2009): A surveillance summary of smoking and review of tobacco control in Jordan. Global Health, 5(18).
- Census Bureau of Jordan (2012): Current Population Report 2012. Accessed September 2012. Retrieved from: http://www.dos.gov.jo/dos_home_a/main/index.htm
- Chaloupka, Frank J. and Rosalie L. Pacula (1998). Limiting Youth Access to Tobacco: The Early Impact of the Synar Amendment on Youth Smoking, Presented at the 3rd Pacific Rim Allied Economic Organizations Conference, January, 1998, and the Second Annual Chicago & Great Lakes HealthServices Research Symposium, March 1998.
- Experts tackle religious, health issues on smoking. The Jordan Times; 2002.
- Jordan Ministry of Health, Directorate of Information and Research: Mortality data in Jordan, 2006. Information and Research Newsletter 2009, 1:1-4.
- Maayeh, S,P., (2003):Jordan: Mass Media Campaign Combating Smoking Requires Serious Commitment and Not Just Words. World Health organization.
- World Health Organization (2011), WHO report on the global tobacco epidemic, 2011: Warning about the dangers of tobacco. World Health Organization - Geneva, Switzerland.
- The National Information System: Jordanian legislation. Accessed September 2012. Retrieved from: http://www.lob.gov.jo/ui/laws/index.jsp