In this section, we will discuss the tobacco control agenda-setting process based on MSF. The findings of this study result from interviews with key informants and documentary analysis (Fig. 1).
Problem stream
Indicators of problem severity
Participants stated that the prevalence of tobacco use has increased in Iran, especially among young adults. It has led to economic losses, which had awakened proponents of tobacco control in the country.
“… 12 to 15 percent of the population, equivalent to 10 to 12 million people in Iran, are smokers. Smoking between the ages of 15 and 24 has risen from 10 to 17 percent in the last ten years. If every smoker consumes 3000 rials per day for cigarettes, between 30 to 40 billion rials will be smoked daily in the country, which will be close to 10000 to 15000 billion rials per year …” (Participant. 33).
The results of the surveys conducted during this period were in line with the interviewees’ statements. In 1991, the first national study was conducted on the prevalence of tobacco use based on the “National Health and Disease Survey” in Iran. The trend of changes showed that the prevalence of tobacco use has decreased (1991–1999) based on two National Health Surveys (in the age group of 15–69 years from 14.6 to 11.7%). Hookah use decreased from 3.8 to 3.5% and followed a similar pattern in the general population, but increased from 0.8 to 1.4% in the age group of 15–24 years; therefore, the results of the National Health and Disease Survey showed an increase in hookah use in the age group of 15 to 24 years [15, 16]. Several other studies were conducted on the prevalence of tobacco use in the country, such as the Global Youth Tobacco Survey (GYTS) [17], which led to the accumulation of valid information about the severity of the problem in Iran.
Interviewees also stated that the gating hypothesis is one of the most important factors that led to tobacco in Iran. It means that tobacco is considered a gateway to addiction and other social crimes.
The interviewees stated that the economic and health consequences are among the most critical factors that led to tobacco use in Iran. Researchers and advocates of tobacco control have to estimate mortality and morbidity information related to tobacco in Iran based on global evidence and production information, although it did not exist.
Some interviewees highlighted the activities of multinational corporations and cigarette smuggling, which increased the access to people in the community, especially young adults. An examination of the documents indicated that multinational tobacco companies considered Iran a viable market for their products and a gateway for smuggling cigarettes from other countries.
“International tobacco companies planned to enter the markets of developing countries after reducing their sales in the domestic market” (Participant. 33).
“Unfortunately, multinational cigarette companies have chosen Iran as a focal point for promoting and expanding cigarettes for two reasons. The major factor is that Iran is a young population of nearly 40 million people under the age of 30, which is a suitable environment and platform for encouraging smoking. Statistics show that quitting smoking is almost impossible for those who start smoking at a young age. Second, Iran is a safe passage for smuggling cigarettes and tobacco because of its strategic location, at a strategic crossroads between Central Asia and Europe” [18].
The role of religion
After the Islamic Revolution of Iran, a group of experts formed a social-religious movement to combat the consumption of tobacco and cigarette companies. They tried to limit tobacco production, smoking in public places, and the promotion of tobacco and various items of cigarettes. Their efforts led to agenda-setting of tobacco control in the country and the approval of the Fatwa (Islamic Order) on the ban of smoking in the Islamic Consultative Assembly in 1992 as a prelude to the development of other tobacco control policies in the country [19, 20].
Framing the issue
Interviewees often referred to the issue of tobacco as a crisis or a social problem. In Iran, during this period, terms were often used to describe the severity of the problem of tobacco use, such as “epidemic”, “scourge”, “social problem”, “social harm” and “colonial gift”.
Policy stream
This process started in 1991 and developed in the early 2001s as a “Comprehensive Plan on National Control and Campaign against Tobacco” as an acceptable and comprehensive solution and advocate for tobacco control.
Feedback from previous policies
The findings of the present study revealed that feedback from past tobacco control policies influenced the policy stream. The interviewees stated that policymakers and actors’ perceptions of the inadequacy, incompleteness, and non-implementation or failure of previous bylaws and directives led to a sense of the need for a comprehensive law. It led to a comprehensive plan to control and combat tobacco use by members of Parliament and then a bill to control tobacco use by the government. Initiatives and plans related to tobacco control as a public health issue go back to 1994 when the tobacco control program was one of the MoHME’s priorities. Therefore, a committee comprising full-fledged representatives of relevant ministries and governmental and non-governmental organizations and health professionals formed the National Committee for Tobacco Control in the general directorate of environmental and occupational health under the supervision of the Deputy Minister of Health. Several attempts failed to formulate tobacco use prevention programs and tobacco control policies in the first half of the 1991s. As a result, the plan was formulated, entitled “how to decrease smoking”, and presented to Parliament. The Islamic Consultative Assembly approved this plan. However, the Guardian Council rejected the plan as unconstitutional due to its financial burden on the government. This law was never implemented, despite the emphasis and stipulation that it must be enforced for all institutions. In 1997, the Council of Ministers approved the regulations relating to the ban on smoking cigarettes and other tobacco products in public places”; but this resolution was not implemented due to the resistance of specific sectors [21]. The content of the regulations were the ban on advertising of the tobacco industry, attaching warning messages on cigarette packs and banning the use and supply of cigarettes and other tobacco products in public places.
Existence of a comprehensive plan for tobacco control
Tobacco control advocates accepted the comprehensive plan to national control and campaign against tobacco, and the basis and provisions of which were based on FCTC and global evidence. NGOs and the MoHME were involved in compiling those as the Parliamentary Health Commission. Several meetings were held with the relevant executive bodies and were placed in various parliamentary commissions to increase the acceptance of this plan. Consultations were held between the speaker and members of parliament to gain advocates and make it acceptable to imitators. Also, during integrating the plan and the bill, the comparative and expert review was entrusted to the Parliamentary Research Center. The center organized meetings with relevant officials, institutions, grassroots organizations, and experts to increase its acceptability and applicability.
Pressures, requirements, treaties, agreements and international law
Framework convention on tobacco control (FCTC)
In 2003, Iran signed the WHO FCTC, considered tobacco control a public health priority, and ratified it in November 2005. In 2006, WHO FCTC was implemented in Iran [20]. This convention encourages countries to implement operational plans, including prevention of direct and indirect tobacco advertising, increasing tobacco tax, promoting smoke-free public places, attaching health warning labels to tobacco packaging. This convention played a vital role in the agenda-setting of the tobacco control policy-making process in Iran.
The 2011 United Nations Policy Declaration on the Prevention and Control of Non-communicable Diseases (NCDs) is a milestone in overcoming non-communicable diseases [22]. Officials have officially stated that NCDs pose a severe threat to health, the economy and society, and therefore have put its control over their agenda-setting.
Sustainable development goals 2030
In 2015, implementing the FCTC was reflected in the sustainable development goals (SDGs) 2030 in Objective 3. a, which is: “Strengthen the implementation of the FCTC in all member countries as appropriate”, and the indicator designated as the monitoring index and the WHO was determined as responsible for it [23].
International organizations
International organizations such as the WHO played a prominent role in the global governance of tobacco control. The WHO is involved in all stages of the policy-making process, including the tobacco control agenda, requiring member states to implement FCTC and develop guidelines, technical advice and financial support, and dissemination of tobacco control knowledge. The United Nations also plays a role in global tobacco control policy by global agenda-setting to prevent and control NCDs, the Millennium Development Goals and the SDGs. The World Bank also plays a role in Iran by advocating for tobacco tax increases, conducting research and advising and guidance and technical assistance on tobacco taxation in Iran.
Political stream
Requiring the expediency council to the government to prepare a bill
In 1992, the Expediency Council ordered the government to prepare and submit a bill to reduce tobacco consumption to the parliament. The Islamic Consultative Assembly approved the proposal “how to gradually reduce and eliminate tobacco use” in 1991. However, the Guardian Council found it contrary to principle 75 of the Constitution of the Islamic Republic of Iran. It was discussed at the meeting of the Expediency Council, and the Expediency Council did not approve the amendment to the proposal. Therefore, this assembly, while approving the opinion of the Guardian Council, expressed that:
“The government should investigate how to reduce tobacco use , by its authority, should directly take the relevant executive measures or prepare a proposed bill and submit it to the Islamic Consultative Assembly” [24].
However, the interviewees stated that 10 years have passed since such a requirement, and failure to prepare a bill by the government caused them to prepare the proposal by representatives of the Islamic Consultative Assembly and tobacco control advocates.
Entering into an international commitment: ratification of the FCTC in the Islamic consultative assembly
In this study, although the political stream had begun to a minimal extent years ago, it crystallized in 2003; When the FCTC, the world’s first evidence-based tobacco control public health treaty, opened in June. This historic achievement meant that it legally required the signatories to deal with tobacco use. After signing the convention in 2003, Iran approved the law on Iran’s accession to the FCTC in 2005 in the Islamic Consultative Assembly. Therefore, Iran joined the FCTC in 2005 and had to implement it. Many of the interviewees stated that Iran’s accession to the FCTC was one of the most important factors influencing the political process, creating political support and commitment regarding tobacco control. WHO FCTC served as a driving force for the adoption and implementation of the Comprehensive Tobacco Control Act after several previous unsuccessful attempts before WHO FCTC ratification.
According to this convention, the member states were committed to implementing comprehensive national strategies for tobacco control. Advocates of tobacco control also used such a requirement to gain support for tobacco control policies. Therefore, following Iran’s accession to the member states of the FCTC, Iran developed a comprehensive law on national tobacco control while actively participating in the convention of this treaty, by paragraph 1b of Article 1, through the national committee for tobacco control.
“The MoHME, as the responsible organization for tobacco control subject to Article (5) of the Convention, must formulate and implement national, comprehensive strategies for tobacco control, and monitor them periodically to achieve this goal in coordination with the executive apparatus, implement training and implementation programs to reduce tobacco consumption. This Ministry will draft the bills and regulations to achieve the convention’s objectives and submit them to the relevant authorities” [25].
“Each Party should develop, implement, periodically update and review comprehensive multisectoral national tobacco control strategies plans and programs by this convention and the protocols” [26].
Opening the opportunity window and joining of all three streams
Most of the interviewees believed that Iran’s access to the FCTC in the political process was the reason for opening the opportunity window. The policy window opened when all three streams had already been developed (Fig. 1). The problem stream was smoking, while the policy stream was a comprehensive plan for national control of tobacco. Members of parliament negotiations presented it and agreements were reached by the advocates of tobacco control and many of the country’s executive apparatuses, and the political climate was prepared for change. In the political stream, Iran undertook to adopt a comprehensive law in this field by signing the FCTC through Iran’s representatives and ratifying Iran’s membership at the convention in 2005. Thus, the three streams were joined, and a policy window opened. The adoption of the Comprehensive Law on Tobacco Control in the Islamic Consultative Assembly in 2006 [27] is considered a turning point in tobacco control activities in Iran.
“But what happened in the world coincided with the bill that was to be drafted by the proposal that the deputies made. The WHO wrote the first international tobacco control treaty based on evidence obtained in various countries. The ministers of health of 192 countries ratified this agreement after five years of expert work and various meetings at the World Assembly of the Health Organization. Fortunately, our representative in Geneva was one of the 20 countries that signed this agreement” (Participant. 33).
Continuity of policy development
After the law’s approval, the national headquarters of control and campaign against tobacco products was established. The executive by-law of this law was developed in 2007 [28]. Before the privatization of the Iranian tobacco company in 2013, attending tobacco industry representatives in policy meetings as a government body was discontinued to ensure compliance with Article 5.3 of the Convention.
While a smoking ban in public places existed before the WHO FCTC, public places were not clearly defined. Two years after ratification, in 2007, Iran implemented a by-law banning tobacco product consumption such as smoking in all public places, workplaces, public transport and outdoor public spaces. In these years, different interpretations of the term “public places” caused the court of administrative justice to rule three times in favour of not offering hookahs in teahouses and traditional restaurants and to annul the approvals of the Council of Ministers and the President. Over 6000 environmental health inspectors were trained to enforce the law and for reporting violations of the bans. In 2007, all direct and indirect forms of tobacco advertising, promotion and sponsorship (TAPS) were prohibited. In 2009, pictorial health warnings on cigarette and tobacco product packaging were implemented [29].
Iran’s MoHME has developed and implemented a wide range of anti-tobacco mass media campaigns collaborating with relevant agencies, including a focus on hookah consumption, youth and females, to raise public awareness. Funding for tobacco control activities has been increased. In 2012, the Ministry of Interior banned the sale and use of e-cigarettes [30].
In 2015, Iran implemented a 14% tobacco tax increase in the budget. The total tax was only 21.7% of the retail price of the most widely sold brand of cigarettes [31], far shorter than 70% recommended [32].
Furthermore, global organizations played a significant role in policy development and implementation by providing FCTC Protocols. In 2014, Iran approved the law on Iran’s access to the WHO FCTC Protocol to eliminate illicit trade in tobacco products [33].