This project is funded through the Economics of Tobacco Control Research Initiative, an IDRC and Cancer Research UK co-funding partnership launched in October 2017. The objective of this partnership is to generate evidence that provides the economic rationale for the prevention of tobacco-related diseases and research uptake by policy actors that allows for the adoption of tobacco-control policies across low- and middle-income countries.
Waterpipe Tobacco Smoking, a dangerous pattern among the population
The Eastern Mediterranean Consortium on the Economics of Waterpipe Tobacco Smoking (ECONWTS)
In Lebanon, estimates have been made of the direct and indirect costs of diseases caused by tobacco among adults over the age of 30. In 2008, these represented USD13.6 million in environmental costs (fires and collecting smoking-related waste) as well as USD102.2 million and USD64.6 million in lost productivity due to morbidity and mortality, respectively.
The aim of this research project was to provide detailed knowledge and recommendations to inform governments of the severity of this growth and encourage them to implement effective policies to curb waterpipe tobacco and cigarette smoking.
The American University of Beirut led this project, having made significant investments in knowledge translation infrastructure, culminating with the launch of the Knowledge to Policy (K2P) Center in 2015.
Waterpipe tobacco smoking (WTS) is a traditional tobacco use method in the Eastern Mediterranean Region (EMR) that has resurfaced in recent decades. The EMR has the highest rates of WTS worldwide, especially among youth, exceeding the rates of cigarette smoking.
Despite its recognized harm, the prevalence of WTS has been growing widely and has been met with a poor regulatory response universally.
Countries in the EMR are in urgent need of effective tobacco control tactics that consider the particularities of WTS products (e.g., lack of product standardization and café-based consumption) to control this epidemic.
Increased taxation on Waterpipe Tobacco would drastically reduce consumption
A cultural practice that is making a comeback.
WTS is a traditional tobacco use method in the Eastern Mediterranean that has resurfaced in recent decades. The EMR has the highest rates of waterpipe tobacco smoking worldwide, especially among youth, exceeding the rates of cigarette smoking. Evidence associates WTS products with nicotine dependence and smoking-related diseases, including cardiovascular disease, cancer, lung disease and adverse pregnancy outcomes. Despite recognized harm, the prevalence of WTS products has been growing widely and has been met with a poor regulatory response universally. Hence, countries in the EMR are in urgent need of effective tobacco control tactics.
The accessibility and sociability of this type of consumption result in dangerous consumption patterns for women.
In Lebanon, for every woman smoking cigarettes, there are 2.2 men. When it comes to waterpipes, there are more women than men smoking them (only 0,9 men for 1 woman).
Whatever the reason is for this phenomenon, it might be that it is more socially acceptable for women to smoke waterpipes compared to cigarettes. Taxation on WTS products should be significant enough to promote women’s health.
Familiarity with tobacco makes it more accessible and socially more common.
Regulating WTS products with high taxation rates conveys a strong public health message about their harm, which is less commonly known than the harm from cigarette use.
Current WTS product taxation rates are much lower than rates on cigarettes and far from the recommended minimum of 75% of product prices. Based on the model that has been developed, a substantial tax increase on WTS products would lead to a significant decrease in consumption (up to 90.1% in Lebanon) as well as to an important increase in annual tax revenue (up to 73.5% in Lebanon).
Team and partners list
Rima Nakkash, PhD, London School of Hygiene and Tropical Medicine, UK
Ramzi Salloum, PhD, University of Florida, USA and Research Affiliate, American University of Beirut, Lebanon
Youssef Khader, PhD, Jordan University of Science and Technology, Jordan
Niveen Abu-Rmeileh, PhD, Birzeit University, West Bank and Gaza
Aya Mostafa, MD, Ain Shams University, Egypt
Ali Chalak, PhD, FAFS, American University of Beirut, Lebanon
Mohammed Jawad, MBBS, MSPH, Imperial College London, UK and Research Affiliate, American University of Beirut, Lebanon
Fadi El Jardali, PhD, FHS, American University of Beirut, Lebanon
Ruba Abla, MPH, American University of Beirut, Lebanon
Methodology and references
In 2019, cross-sectional household surveys were conducted in Lebanon, Jordan and the West Bank and Gaza to collect information on waterpipe and cigarette smoking prevalence and consumption behaviours.
Conducting a similar survey in Egypt was not possible, but a literature review was done on the latest national surveys conducted in Egypt about tobacco use and household income and expenditure. (The relevant latest national surveys were STEPS 2017 by the Ministry of Health and Population and the Household Income, Expenditure, and Consumption Survey 2017/2018 by the Central Agency for Population Mobilization and Statistics).
This information was used to estimate the price elasticity of demand (a measurement of the change in consumption of a product in relation to a change in its price) for cigarettes and WTS products and the cross-price elasticity between cigarettes and WTS products.
The cross elasticity of demand measures the responsiveness in the quantity demanded of one good when the price changes for another good. The cross elasticity of demand for substitute goods is always positive because the demand for one good increases when the price for the substitute good increases. Alternatively, the cross elasticity of demand for complementary goods is negative.
Based on the estimates of elasticity obtained, a waterpipe tobacco simulation was developed to evaluate the impact of fiscal policies for waterpipe tobacco control on consumption rates, health care costs and public revenues. It used country-specific tax structures, price data, consumption data and market shares to calculate the total market value, tax revenue and industry revenue.
Promoting key learnings
Celebrating the culmination of over a decade of partnerships, research and advocacy, a webinar was planned in partnership with Cancer Research UK, “Demystifying the Economics of Tobacco Control: Knowledge, policy and everything in between,” and broadcast live on June 29, 2022.
This webinar represented an opportunity to demystify the process of knowledge translation, to share key learnings from our research teams across the globe and to discuss the emerging opportunities for continued and meaningful impact.
The Call for Concept Notes on the Economics of Tobacco Control in Low and Middle- Income Countries offered up to CAD1 million over a maximum of four years to support evidence-based research on the economic rationale for the adoption of tobacco-control policies across LMICs in four regions: Asia, Latin America and the Caribbean, the Middle East and North Africa, and sub-Saharan Africa.
By targeting collaborative, applied economics research, the Initiative aimed to support the implementation of effective fiscal and other policy measures to help prevent tobacco-related diseases and save lives.