Do Iranian tobacco growers support the World Health Organization framework convention on tobacco control?

CONTEXT: Studies on the World Health Organization Frame-work Convention on Tobacco Control (FCTC) are scarce in Iran and the Eastern Mediterranean region (EMR). AIM: This study was conducted in 2007-2008 in Iran to design a practical evaluation model of the implementation of FCTC with the potential to be adopted in the EMR. Given that, the findings of this evaluation can be useful in increasing political and public support for enforcing the implementation of legislations, testing their feasibility, and maintaining sustainability. The viewpoints of tobacco growers as part of stakeholders in this regardwould have an influential role. SETTINGS AND
DESIGN: This study was a qualitative one to investigate the tobacco growers viewpoints about thestrengths/weaknesses of FCTC implementation in Iran.
MATERIALS AND METHODS: In this study, we conducted semi-structured in-depth individual interviews with 5 tobacco growers. All interviews were carried out with their permissionwere recorded and were assured that their interviews will be kept confidential. All questions were related to different FCTC articles, then written transcripts were prepared and the basic concepts were extrapolated. STATISTICAL ANALYSIS: After transcribing the recorded interviews, we extracted first level codes and main concepts from them.
RESULTS: The findings suggested that although tobacco growers agreed with FCTC implementation, however, subjects like the necessity to support tobacco growers and obtaining insurance from the government, the necessity of the enforcement of national tobacco control law and planning to decrease access to tobacco by policy makers were the most key points that tobacco growers pointed to them.
CONCLUSION: Our results showed that tobacco growers agreed with the implementation of FCTC but they worried about their job and the expenses of their daily life. Therefore, it seems that policy makers have to design a plan to support tobacco growers for changing tobacco with a safe cultivate.

INTRODUCTION

Tobacco use is the largest preventable cause of disease and death world-wide and is causing about 5 million deaths annually, a toll projected to rise to 10 million by the 2020, 70% of whichwill be in developing countries.[1] Therefore, in response to the globalization of the tobacco epidemic, the World Health Organization (WHO) ratified the Frame-work Convention of Tobacco Control (FCTC). It was adopted by the World Health Assembly on 21 May 2003 and entered into force on 27 February 2005. In 2004, 168 countries including Iran signed it and undertook it as an evidence-based public-health priority that reaffirms the right of all people to the highest standard of health.[23]

According to WHO, the FCTC sets forth that its ultimate objective is “to protect present and future generations from the devastating health, social, environmental, and economic consequences of tobacco consumption and exposure to tobacco smoke….”[23]

The convention represents a milestone for the promotion of public-health and provides new legal dimensions for international health cooperation. The ratification of the FCTC is a critical matter since it represents a milestone in the history of public-health and corporate responsibility. The treaty is aimed at reversing the global tobacco epidemic and to hold tobacco companies responsible for the harm they cause to the citizens of the world.[4]

One of the most important indices of its applicability was defining the priority and policies to obtain maximum effectiveness with limited resources and budget; nonetheless, individual perceptions and tastes posed difficulties in the performance of the program.[4]

The International Association of Tobacco Growers considers the WHO tobacco control policies responsible for reduced amount of land to grow tobacco in the Americas and for worsened life of many farmers. Despite to these declarations, the area of land under tobacco and hence its production increased during 1990-2000 (from 471,975 to 505,636 hectares and from 703,431 to 868,302 metric tons, respectively). On the other hand, the decline harvests in some countries are a result of lower prices that have in turn been caused by surplus production in the world. The measures taken by the WHO will not affect the current generation of tobacco growers because, even if the prevalence of smoking does decline, the total number of smokers will continue to grow due to the overall increase in the size of the population.[5]

Evaluation of such comprehensive approaches for tobacco control at the community level is an important component to the community level is an important component to determine its impacts and outcomes. Furthermore, it help in showing whether these programs succeed to achieve its pre-planned objectives or not, and to which extent it is feasible and sustainable.[67]

Therefore, most of such program include an extensive evaluation programs that consist of process, impact and outcome evaluation.[7]

WHO used a brief questionnaire asking for the implementation of each article that should be completed by the related staff in the Ministries of Health in each country.[8]

However, the International Tobacco Controlpolicy evaluation outcome, which is still ongoing in more than 20 countries to evaluate the implementation of FCTC and assist its long-term results, is more comprehensive and include multiple questions at the population level with a prospective design.[9] Smoking habits and it's determinants as well as socio-economic and cultural beliefs that needs to be addressed in the evaluation model of FCTC are deferent in different regions in the world, As there is no FCTC implementation in the Eastern Mediterranean region (EMR), therefore, we conducted a study in 2007-2009, to develop an evaluation model for this reason. The study was carried out to investigate the policymakers, stakeholders, and the community in general view points and their suggestions on the implementation of FCTC articles in Iran.[1011]

The viewpoints of tobacco growers as one of stakeholders groups in this regard would have an influential role in increasing political and public support for strengthening of legislations and in increasing their feasibility and sustainability. In this paper, we report the tobacco growers’ viewpoints and suggestions about the strengths/weaknesses of the implementation of FCTC articles at the national level, as well as the best methods for improving its performance.

MATERIALS AND METHODS

This study was part of a large study on designing a model of FCTC evaluation and monitoring in Iran. The main study was a qualitative one in which the indicators extraction and model designing of evaluation was carried out after doing in-depth semi-structured individual interviews with policymakers, stakeholders and general population. Stakeholders were divided in three groups: (1) Sellers of tobacco products; (2) owners of restaurants, teahouses, coffee shops; and (3) tobacco growers.[1011]

Data of this qualitative research were collected by individual interviews. Taken into account that qualitative research is conducted on people aware of topics related to the study, we selected purposive participants. Written informed consent was taken after explaining the objectives of study, moreover, we got their permission to record the interviews, and we assured them that their speeches will be kept confidential.

Interview with tobacco growers was carried out by trained interviewers after coordination with work and environmental health office and introducing the interviewers to participants.

The interviewers were research assistants with experience on similar interviews in other research studies; they became familiar with FCTC and the current study by attending more than 3 sessions organized by our project. The interviews were semi-structured; each lasted about 45-60 min and was conducted in an extrapolative manner withand general questions. During the interviews, no clues or directions were provided by the interviewers and only when the interviewees seemed to digress, they were led back to the question at hand.

General questions that were asked from the participants were as follows:

Do you know about FCTC?

Do you agree or disagree with FCTC? What are your reasons?

What methods do you suggest for control of tobaccouse?

Have you ever received any guide direction about the amount of tobacco cultivation?

How would you been supported by government in cultivation and production of tobacco? Has taken place any changes in governmental supports in recent months?

Does FCTC implementation have any benefits or risks for you?

Have you ever heard any health messages about tobacco control from mass media? What's your opinion about them?

Which organization can control tobacco use better?

All interviews were recorded, then the written transcript was prepared and reviewed several times by the interviewer and all the sub-concepts of meaning were extracted. The perceived meanings were classified into more generalized concepts and the process continued until basic concepts were extrapolated. All of the materials and data were reassessed by a qualitative analyst, a faculty member of Isfahan University of Medical Sciences with good expertise in previous qualitative researches at the national level. The same process was applied until extrapolation of basic concepts was complete. The interviews continued until a level of information saturation was reached. Five interviews were conducted for tobacco growers. Reconstructed meanings were rechecked by participants to assure from the accuracy of extracted meanings. A scientific committee whose members were expert people on FCTC and qualitative studies has evaluated and confirmed all of the codes and concepts.

RESULTS

Based on the qualitative study conducted by using information collected from 5 tobacco growers, 47 first level codes were extracted and the following major concepts were obtained. The findings suggest that the following concepts have role in promoting effective implementation of FCTC:

Necessity of tobacco growers’ support and insurance by thegovernment

Necessity of the enforcement of tobacco control law

Planning to decrease access to tobacco by policymakers.

Necessity of tobacco grower's support and insurance by government

The importance of tobacco grower's support and insurance is evident from the participants’ statements:

“…. It's near to 50 years that we cultivate tobacco, however, our expenditure has increased and the cost of each acre is 300 $. We don't receive adequate chemical fertilizer. We need 6-7 bags of chemical fertilizer (each bag contain 50 kg) but tobacco company only gives us 1 bag.” (Participant no. 1).

“… Since, the implementation of tobacco control law will decrease cigarette and waterpipe smoking policy makers must support us to substitute other things such as Colza flowers that produce oil to be cultivated. Now, we receive chemical fertilizer lower than our need. We must be became insured, because tobacco growing is our job for more than 50 years and we can't do any other work…” (Participant no. 2).

“… Almost all of us are in old age and some disabled. Policy makers must cover us by insurance, at least health insurance, so we can visit doctors easily. We need to have a fix salary…” (Participant no. 4). This point was also referred by Participant no. 5.

“… The pests have increased and damaged our products, but the support of tobacco companies for giving us pesticide doesn't have changed…” (Participant no. 5).

Necessity of the enforcement of tobacco control law

The study findings revealed that all of tobacco growers knew the adverse effects of tobacco smoking on health and despite tobacco growing is their job, they believe that policymakers should limit access to tobacco and decrease its production.

The following statements support our findings:

“… We agree with tobacco control policies, because it has several harmful effects on health and we worry that our children become smokers. Opium use must become forbidden, too….” (Participant no. 1) Another participant (no. 2) referred to this point, as well.

“… Radio and television broadcasting should design educational messages about the adverse effects of tobacco and water pipe smoking and fruity tobacco on health…” (Participant no. 5)

“…. Policymakers should adopt some strategies to decrease tobacco smoking with emphasis on prohibiting the sale of tobacco to peopleyounger than 18 years old that are more influenced by peers…” (Participant no. 4).

“…. I think that the limitation in access to tobacco leads to decrease in tendency to tobacco smoking. Health massage to inform adults about health hazards of smoking and its related diseases are very useful. These objectives will be achieved through implementation of tobacco control policies (Participant no. 3).

Planning to decrease access to tobacco by policy makers

“…. I believe that initially, policy makers and government must limit tobacco cultivation to successesin tobacco controlling…” (Participant no. 3).

“…. The government is responsible for tobacco controlling in the community, so policymakers should design effective strategies to overcome tobacco smoking…” (Participant no. 2).

DISCUSSION

The current study assessed the tobacco grower's viewpoints about implementation of FCTC in Iran in order to identify and determine some of the impediments, causes and challenges that influence the implementation of FCTC. The findings suggested that although, this group agreed with FCTC implementation and were aware of tobacco hazards even for their children, however, some factors such as the necessity to be supported and covered by health insurance by the government, the necessity of the enforcement of tobacco control law, planning to decrease access to tobacco by policy makers were the key points that tobacco growers pointed to them.

Tobacco grower's viewpoints in our study were in line with policy makers viewpoints about tobacco control policies and implementation of FCTC. For instance, a study in Korea showed that policy makers believe that the Tobacco Business Act, which aims to promote tobacco business, is entirely in opposition to the establishment of active social welfare policies for the quality improvement of people's lives. Thus, it should be abolished to meet and follow the implementation of the FCTC an international desire for health trend. Moreover, the revision of the national health promotion Act was considered necessary to secure the enforcement and implementation of this program in Korea.[3]

Another study referred to this subject that international regulatory strategy, such as the FCTC is required for tobacco controlling.[12] Furthermore, the role of the public-health civil society groups to ask policymakers and governments to recognize the importance of not working with the tobacco industries.[1] Given that, cigarette producing companies and leaf dealers are the only buyers of tobacco leaf, therefore, individual farmers are reluctant to publicly criticize theirpractices out of fear of relation. However, fortunatelytobacco farmers have been gradually waking up to the realization that the cigarette companies are not their friends. In addition tobacco growers and the public health community in the UnitedStates have established an ongoing dialogue on issues of common concern and agreed upon “care principles” to both protect public-health and the economic stability of tobacco-dependent communities.[13]

In Zimbabwe, the most respect to the legal rights of tobacco grower's to produce tobacco, is that it is not an illicit drug[13] and tobacco growers produce 82% of Zimbabwe's horticulture, one of the faster-growing export earners in Zimbabwe, which utilizes only 3% of the nation's arable landand hence, they are concerned about the proposed FCTC that has been put on a fast-track passage with little attention to its serious negative impact on the whole nations. As a result, more research should be undertaken on impact and needs of tobacco led economies and some support is necessary for transition assistance for affected farmers and government must guarantee tobacco growers against future losses.[14]

The food and agriculture organization suggested that we need to remember that the conditions of farmers in many developing countries are very different from those in high income countries where farmers, even though they are also adversely affected by the contraction of markets, certainly have more opportunities to move into alternative activities.[14] The results of our study showed that all of tobacco growers pointed to the necessity of being supported and covered by health insurance by the government, hence it should be motioned by policymakers to decrease their concerns about health and earning especially, after they become disable. Therefore, it is suggested that policy makers should select strategies and policies that all rights of tobacco growers be reserved.

In our study, substituting other plants such as colza cultivation that is the main source of Canola oil was noted by tobacco growers. This subject shows that tobacco growers agree with the implementation of FCTC and are aware of the adverse effects of smoking; consequently, shifting tobacco growing to suitable alternative must be considered. However, it must be noted that a successful shift from tobacco growing to alternatives requires profitability, the provision of technical and financial assistance, capacity building and market and social support, not overlooking the transition period. Public policies, including intersectoral approaches are required in order to take full advantage of the existing resources and opportunities. Farmers should be involved in decision making and must therefore, be given adequate channels to voice their needs and concerns.[15]

It seems that FCTC in its final form must pay careful attention to the social, cultural, political, and economic needs and special circumstances of the country particularly in the developing countries like our country, in which cultivating tobacco is of important economic concern. Larger studies on tobacco growers and other stakeholders are needed and adding few questions in the FCTC evaluation questionnaire is suggested

Strengths and limitations

This study was the first study that investigated tobacco grower viewpoints on FCTC implementation in Iran and the EMR. As tobacco is cultivated in many parts of Iran, therefore, we have to interview other tobacco growers in different partsof our country, but because of our budgets and facilities limitation, we studied tobacco growers in Isfahan and Najafabad, which is an important limitation of our study.

CONCLUSION

Our study showed that tobacco growers were awarded of tobacco hazards, agreed with FCTC implementation and addressed the important role of the policymakers and the government. In this regard, however, they referred to their need to be supported by the government to change their job, to be covered by health insurance and to be assisted in their future life.