Policy makers' viewpoints on implementation of the World Health Organization Framework Convention on Tobacco Control in Iran: A qualitative investigation of program facilitators.

BACKGROUND: The epidemic of smoking is a great concern of health systems. Moreover, the number of smokers is increasing worldwide and this has led to an escalating trend of morbidity, mortality, and burden of smoking-related diseases. Therefore, monitoring the implementation of tobacco control laws in different countries is of extreme importance. This study aimed to describe policy makers' experiences and perceptions of the facilitating factors of the implementation of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) in Iran.
METHODS: This was a qualitative research in which data were collected through individual interviews. The participants included policy makers who were members of the national assembly for tobacco control. In this study, 13 unstructured interviews of about 45 to 60 minutes duration were conducted in an extrapolative manner. The qualitative content analysis method was applied until extrapolation of basic themes was complete.
RESULTS: As a result of the analysis, the themes of performance through training, through research, through intersectoral collaboration, and through setting priorities emerged. The emerged themes connote some critical points that have key roles in promoting the effective implementation of the WHO FCTC. Furthermore, the main role of the health sector becomes predominant.
CONCLUSION: The study findings suggested the managed and coordinated work as one of the main facilitating factors of the implementation of the WHO FCTC at a national level.

Introduction

The epidemic of smoking is increasing worldwide and has expanded from high-income countries to low-income regions1 and it has led to an escalating trend of morbidity, mortality and burden of the smoking-related diseases.2 Tobacco use is now widely recognized to be the single most important preventable cause of health problems worldwide;1 it is, therefore, imperative that preventive action is taken against its health hazards.

Similar to many other developing countries, smoking is a public health concern in Iran, with a prevalence of 34.7% among males and 6.7% among females.3 The mean age of beginning smoking is 13 years.4 Now the smoking has a great economic and disease burden for all age groups in the Iranian Society.5 Consequently, in response to this challenge, in 2003, the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) was developed in 38 articles, as the first treaty negotiated under the auspices of this organization.6 The treaty was adopted by the 56th World Health Assembly (WHA). Coming into force on February 27, 2005, the FCTC was signed by 168 countries7 including Iran8 and was undertook as an evidence-based public health priority that reaffirms the right of all people to the highest standard of health.

For implementation of FCTC, countries had to ratify their signatures. At the commencement, 40 countries ratified it, and the rest of them ratified it from April 2006. The follow-up and reporting of FCTC implementation is being done by the United Nations Secretariat.

Right away after its approval, according to the first article of this law, the national assembly of tobacco control was structured with the membership of the Ministers of Health and Medical Education, Training and Education and Commerce, as well as the chief of military power, two representative of the parliament health commission, director of national radio and television broadcasting organization and the representative of one non-governmental organization. Codification of this regulation, its implementation and monitoring are assigned by this assembly, and its members are the stakeholders of tobacco and health at country level.

Now the successful implementation of the FCTC regulation needs a great commitment from the health system in collaboration with other related sectors. As considered in FCTC design, “effective laws must not only prescribe evidence-based measures to protect health, but also provide a clear and comprehensive framework that will maximize compliance, ease enforcement, facilitate inspection and monitoring, and minimize the risk of confusion and legal challenge.”6 Therefore, monitoring and evaluation of the implementation of tobacco control laws in different countries is extremely important.

Several studies have tried to discover the influencing factors (consisted of facilitating and restraining factors) of the implementation of the FCTC.9-12 Nevertheless, there was no similar study in Iran. Therefore, the main study was conducted in 2007-2008 to design a practical model of evaluation of FCTC implementation in Iran with the potential to be adopted in the region.13 Data were updated and analyzed since 2012. The present study that reports a part of findings of the main study, aimed to introduce some of the main facilitating factors of the implementation of the FCTC in Iran based on the policy makers’ experiences and perceptions.

Materials and Methods

A thematic analysis method14 is followed as an appropriate way to study of the participants’ experiences and perceptions in a natural context.

This nationwide study was conducted in Iran. The steering committee was established in Isfahan Cardiovascular Research Center, Iran. The study participants consisted of policy makers who were the members of the national assembly for tobacco control. The eligible policymakers were recruited to the study through purposive sampling method and were interviewed individually. 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. The interview was unstructured; each interview lasted about 45-60 minutes. General question that was asked from the participants were as follows: Please fell your experiences about participating in designing or implementation of FCTC in Iran. 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.

A thematic analysis method14 was used to analyze the data. The transcripts were read and coded by the two independent researchers. The common codes then were merged to develop related themes and sub-themes using constant comparative analysis. Theme choices were discussed in research team, and the final results were reviewed and agreed by the team members.

An adequate number of participants was recruited to support trustworthiness of the study. Moreover, text coding and data analysis were performed by the two researchers independently to ensure consistency and finally, a level of saturation was reached through the analytical process. Data were collected by the digital audio recorder and recorded interviews were transcribed verbatim to prevent any missing in the data.

Results

A total of 13 policy-makers were interviewed. The following themes have identified as key facilitators to effective implementation of FCTC: (1) doing through training, (2) doing through research, (3) doing through intersectoral collaboration, and (4) doing through setting priorities.

Based on the findings, training was identified as an appropriate method of ensuring general population and policymakers’ readiness to accept and follow the FCTC regulations.

Training of policymakers: As it is evident from the participant’s statements, the policymakers’ training about the strategies, benefits, and limitations of the FCTC is important to ensure their favorable knowledge and attitudes:

“…policymakers’ knowledge about smoking and its harmful effect on community health should increase, and their attitude toward it must change, it can be obtained only through education …” (Participant no. 6).

“…policymakers are decision makers and have key role in carrying out the law, therefore, they should have comprehensive information about FCTC, …” (Participant’s no. 3).

The two above sentences refer to this point that periodic education is necessary for policymakers.

Training of general population: General populations are someone who supposed to get benefit from the disease prevention and health promotion strategies such as FCTC. Therefore, it would be important to get sensitized about the health risks and get ready to accept and follow the health promoting directions. Based on the findings, it could be reached through excellent target specific public announcements.

“….designing the caution label on cigarette pockets is one of the ways to inform people about negative outcomes of smoking as a high risk behavior ….” (Participant no. 10), participant no. 8 and 13 referred to this subject as well.

“.…radio and television broadcasting should have various continuous regular educational programs designed for different age groups about the adverse effects of smoking water pipe on health and introducing it as a high risk behavior to the general population….” (Participant no. 2).

Another participant (no. 13) referred to this point that even negative characters in films should not smoke because this would act as an indirect type of appealing youths to smoking. ”….publications and newspapers are an appropriate media for educating the general population about harmful effects of smoking and giving them an opinion to stop smoking….” (Participant no. 1).

Moreover, the findings revealed the importance of training, organizations, and medical universities besides the individual and public levels of training because of their key roles in the community.

“….education and training organization and medical universities have key roles in preventing the configuration of high risk behaviors through arrangement of educational course about smoking, its harmful effects, health hazards and related diseases….” (Participant no. 9).

Strengthening the psychosocial skills was identified as another important training need of population.

“Training the skill of telling no specially to peers, as well as self- regulation are very important in preventing the tendency to high risk behaviors such as smoking….” (Participant no. 7).

The participants believed that the establishment of research and monitoring system would be a key factor to ensure appropriate implementation of the FCTC, although they pointed out that sometimes lack of such system has challenged them in needs assessment and establish tailored regulations and directions. The following statements support our findings:

“….. we do not have a surveillance system for regular collection of valid statistics about trend of smoking in different provinces …” (Participant no. 5).

“…. the reasons of the tendency of adolescents to smoking should be assessed…” (Participant no. 2).

The study findings revealed that correct implementation, as well as follow-up of the implementation of interventions at community level would take place within a host of formal and informal intersectoral collaboration. This can be concluded from the following participants’ statements who perceived the cooperation and collaboration as one of the main predictors of success in such a national level health related program:

“Based on my experiences … cooperation and coordination between tobacco production company and the Ministry of Agriculture for decision making about cultivating tobacco and related cultivated area is necessary….” (Participant no. 2).

“…. Interaction between governmental and private quarters and follow-up of the common strategies is of high importance….” (Participant no. 3).

Some of the other participants (no. 7, 11, 13, 1, 10, 4, 6 and 9) also believed that various organizations should be united for proper implementation of FCTC in the country.

The study findings revealed that the policymakers could approach the aims of disease prevention and health promotion through setting strategies and priorities of the program. They should also introduce the policies and directions to the stakeholders and the program audiences. Defining rubrics means delineation of a standard of performance for the program audiences. In this study, samples of rubrics was smoking prohibition in roofed places, revising tobacco control policies, smuggling control, increasing the taxes and prices of tobacco products, establishment of tobacco cessation clinics and counseling centers, issuance sale justification for some limited stores with emphasis on prohibit the sale of tobacco to younger people, regular feedback to policymakers about the program progress, practicable decision making about waterpipe use, amount of tobacco cultivation and alternative cultures bear testimony to the executive strategies of implementing FCTC.

The participants emphasized that the strategies and priorities of the program should be outlined and clarified for the program audiences. The following sample statements support our findings:

“…. Smoking in roofed places is forbidden, this rule needs reinforcement. I think that non-smokers individuals can be good supportive group for this program…” (Participant no. 2).

“…. Smoking cessation clinics can give good direction and counseling to people….” (Participant no. 6).

Discussion

The current study aimed to explore and describe the policymakers’ experiences and perceptions about facilitating factors of implementation of FCTC in Iran. The findings showed that some factors such as training, search, intersectoral collaboration, identifying strategies, and priorities have key roles in the implementation of FCTC in Iran. Our findings are supported by some researchers who have considered some similar issues as key areas that should be considered in tobacco control.15 The key role of collaboration to succeed health programs and other initiatives have emphasized in the literature.16-18

Doing through training has been perceived as a main strategy through which policy makers attempted to make the stakeholders aware of tobacco control regulations and make them ready to accept and join to tobacco control activities. Therefore, it would be worthwhile to recommend that the health professionals along with people get culture and region specific training. It is demonstrated that lower levels of education and income are associated with higher nicotine dependence and higher heaviness of smoking scores, respectively.19 Such evidence pose a special responsibility on governments and policymakers to pay more attention to such vulnerable populations and to design some appropriate practical programs for them.

As pursued by Philip Morris, because of core similarities in the lifestyles and needs of young tobacco consumers worldwide, standardized global marketing efforts can be adopted as a central advertising production bank along with creating regionally appropriate individual advertisements.20 International Tobacco Control project confirmed previous studies that had formed the evidence base for the FCTC policy recommendations, particularly the use of graphic warning labels banning of “light” and “mild” descriptors, smoking bans, increasing tax and price, banning tobacco advertisements and using new cigarette product testing methods.21

Another way of promoting tobacco control interventions has been focused on establishing a research and monitoring system through which the policy makers, health professionals as well as people get valid information about the trends of smoking and tobacco control in particular regions. It is demonstrated that integrating evidence-based practice for tobacco control is of particular importance for the people. Therefore, the strategic efforts must be directed at advancing applied health researches that evaluated best educational strategies for promoting tobacco control.22

Other researchers have supported our study participants’ perception of the importance of intersectoral cooperation and collaboration as one of the main predictors of success in the tobacco control program.23 The Tobacco Control Program is an excellent situation in which legislators and policy makers of business, education and management sectors could collaborate to reinforce strategies to develop non-smoking and quit-smoking initiatives.24

As our study findings showed, another way of ensuring successfully establishing tobacco control initiative is doing through defining rubrics. This idea is also supported and piloted internationally. As an example, in 2003, India has passed its national tobacco control legislation (India Tobacco Control Act) which consisted of provisions to reduce tobacco use and protect citizens from exposure to smoke; which was found to be effective in reducing prevalence of tobacco use and reduction in the expenditures related to tobacco use in this country.25 Another study revealed that workplace intervention aiming to help individuals to quit smoking, and consistent evidence was found that workplace tobacco policies and bans can decrease cigarette consumption during the working day by smokers and exposure of non-smoking employees to environmental tobacco smoke at work.26 Similarly, a study in New-Zealand revealed that the scientific and public health case for introducing comprehensive smoke-free legislation that would cover all indoor places and workplaces should be considered a public health priority for legislators.2 However, some evidence revealed that existing inconsistencies about the tobacco control directions and legislations may lead to raise disadvantages. For example, Park et al.27 have emphasized on the Korean policymakers’ disagree with the Tobacco Business Act, which aims to improve tobacco business. They believe that this is entirely incompatible with the establishment of active social welfare policies to improve the quality of people’s lives.

Hence, it is critical to be sure that the rules and strategies are clearer and consistent with policies to promote health.

Conclusion

The FCTC is considered as an international program to promote public health through reducing the health consequences of tobacco use. In this regard, the points of view of all stakeholders should be taken into account for developing practical and sustainable interventions for this convention. Moreover, scientific evidence shall be used to guide the formulation of evidence-based tobacco control policies. As suggested by the stakeholders in the current study, periodically update and review of the well-defined, comprehensive multisectoral national tobacco control strategies, plan, and programs in agreement with FCTC and policy evaluation studies are necessary to determine policy impact and potential synergies across policies.