Points to Consider Regarding Tobacco Hindrance

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act properly on some aspects of the MPOWER strategy. First is direct and indirect advertisement on multimedia. Direct advertisements enforce tobacco industries to use unattractive colorless packing with life-threatening graphs and texts on it. There is only some graphical inhibition on Iranian market products that are not effective enough to halt or reduce tobacco consumption. There is no executive law in Iran to ban or reduce indirect smoking advertisements by celebrities through movies in cinema, TV or theaters or cyberspace, while the effectiveness of indirect advertisement ban policies on smoking initiation in minor or young adults has been demonstrated previously. 4 Another issue is tax legislation on tobacco products. Raising tax on cigarette is a challenging argument between the Iranian Ministry of Health and Parliament. 3 The main argument from the Parliament is low control on boundaries which result in the trafficking of tobacco products at a low price. 7 Increasing tax on domestic products will result in bankruptcy of domestic tobacco industries and consequently, higher level of unemployment in the country. However, in 2018, the Parliament approved a 10% increase on cigarette price as a means for reducing cigarette use. This is a good sign but certainly not enough of a response from the Parliament's side.
The last issue is smoke-free available laws and enforcement. Based on the WHO report on global tobacco epidemic in 2019, a complete smoke-free law is not available or executed in restaurants and coffee shops, but they are available in other public places such as transportation, workplaces, and educational facilities except universities. 4 Universities are not ultimate but have acceptable prohibiting laws. However, the compliance score on smoke-free air laws in Iran is 8 out of 10, which is a good sign.
Despite all limitations, Iran ranked first in terms of the policy, legislation, and implementation of tobacco control laws in the East Mediterranean region, 8 but it is still far from developed countries. In this regard, we need to urgently update and implement policies for decreasing tobacco consumption. To achieve this aim, we should have an overview of the most effective policies which have been used in other success stories. These policies include cigarette taxes, smoke-free air laws, comprehensive tobacco control programs, and marketing bans. These are reported to have an important role in reducing smoking prevalence. Cessation management policies and illustrated health warnings also reduce smoking in combination with quitting efforts strategies. 8,9 There is scant large-scale evidence on the impact of health warnings due to tobacco industries' power and money and their impact on the market. 2 Based on the WHO reports in 2019, 4 Iran needs to concentrate on price policies and taxing, marketing bans, and health warnings.

Price Policies and Taxing
Increasing the cigarette tax raises the purchase price. 2 A 10% price increase will cause 1.8% and 1.9% decrease in prevalence and quantity of cigarette smoking, respectively. 7 There are some points that need attention on this issue. First, the prevalence of quitting may highly fluctuate in young and low-income individuals. Second, the effectiveness of tobacco tax policies may not be feasible if the tax does not increase with income. It is well known that price effects depend on cigarette affordability. 2,7,9 Tax and affordability of cigarettes are issues that have not been addressed properly in Iran. 3,4 The Iranian Parliament needs to consider taxation as a critical issue for controlling national smoking.

Marketing Bans
Marketing restriction includes the prohibition on direct or indirect advertisements on mass media, billboards, TV productions, and cinemas, plus complete selling prohibition in the market. 7 The former is only implemented in developed societies with high social awareness and low smoking prevalence. Complete ban strategy on selling cigarettes in the market is not feasible, although there are some small samples available in the literature. 2 Hence, advertising prohibitions have been associated with a higher rate of cessation, mainly in highly educated groups and show long term effects on smoking commencements. A complete advertising ban reduces smoking prevalence by 4% and 6% in the short-and longterm, respectively. 7 So, Iran needs to implement more practical and executable strategies and laws for increasing prohibition on indirect advertisement through mass media to reduce the prevalence of smoking and reverse the trend.

Health Warnings
Picture warnings show to have a 13% reduction in adult smoking prevalence. It also prevents nearly two-third of young adult from starting smoking in developed countries. However, the long-term effect of picture warnings is controversial, since individuals may get used to the appearance. There is limited evidence on the effect of plain packing. 7 However, no laws are available on the obligation of plain packing in Iran. 4

Smoke-Free Air Laws
Comprehensive smoke-free air laws that cover all indoor work places, restaurants and coffee shops are associated with 10% reduction in short-term relative risk of prevalence of smoking compared to no law. 7 However, it is obvious that smoke-free policies have smaller effect in countries with low compliance due to fragile enforcement or absence of anti-tobacco social norms. 10 Each policy may work completely differently in the context of variable societies with different socioeconomic status and education levels. Choosing a single policy is condemned to failure in most cases. Implementation of combined policies may raise the amount of success in all countries. 7,9 Compared to developed countries, Iran has a huge gap in ratification and execution laws in the advertisement, smoke-free laws in restaurants and coffee shops, and tax strategies. 4 It is recommended to consider this issue as a priority in the serious national fight against tobacco abuse.