Building on Success in Tobacco Control: A Roadmap Towards Tobacco-Free Oman (Perspective Review)

There is no national comprehensive tobacco control legislation in Oman that aims to accelerate progress in implementing FCTC measures and reducing tobacco use, Table 2²¹. Even after almost two decades since Oman ratified the FCTC, the country is still striving to implement the best practice approach under the FCTC's core demand reduction and supply reduction measures ⁸. Although Oman’s national health goal for 2040 is to create a healthy society free of health risks and hazards ²², evidence on incorporating tobacco control measures into national health strategies or other national strategies is limited ²². For the last decade, the resources allocated to further develop tobacco control initiatives in Oman have been limited.

Article 2.1 urges Parties to go beyond the FCTC recommendations and implement the most stringent tobacco control measures ⁷; however, this is not the situation in Oman. In fact, some nations have already gone beyond the FCTC recommendations to seek to end tobacco use in their nations, with special emphasis on supply reduction measures ²³. Oman can achieve this target provided it has strong tobacco control legislation in place to facilitate the development, implementation, and enforcement of different tobacco control measures.

While tobacco industry interference has affected every nation, some governments have actively taken measures to defend their health laws, while others are still striving to do so ²⁴. Article 5.3 urges parties to protect their public health policies from the commercial and other vested interests of the tobacco industry ⁷. This requires action from the whole government, not just the health sector, to eliminate the tobacco industry's interference ²⁴. In Oman, the tobacco industry is not permitted to participate in the multisectoral committee that develops public health policy or to accept aid in developing tobacco control policy ²¹. However, the tobacco industry is not prohibited from advertising itself through corporate social responsibility (CSR) and sponsoring events, activities, and individuals ²⁴.

Phillip Morris' distributor, for example, has inked multiple Memoranda of Understanding with the public sector, including an exclusive sponsorship agreement supporting sporting events, providing training for Omani youngsters, and donating different health and education equipment and supplies to local public health and education institutions. American Tobacco, on the other hand, has offered a corporate social responsibility programme through "Enhance Oman" for individuals and non-profit organisations, including supporting a National Environmental Forum as well as donating to a tertiary care hospital in the city of Muscat ²⁴.

Other strategies employed by the tobacco industry include establishing relationships with influential officials, utilising regional diplomatic missions to influence Omani policymakers, opposing smoking bans, delaying regulations to reduce the tar and nicotine content of cigarettes, circumventing a ban on tobacco advertising, promotion, and sponsorship, and offering voluntary codes as an alternative to effective regulations ²⁵. Data on tobacco industry tactics during the COVID-19 pandemic is not clear, although the global figure shows that the tobacco industry capitalised by donating personal protective equipment, testing kits, and investing in research and vaccine development ²⁶. According to the Global Tobacco Industry Index survey of eighty nations on how governments are responding to tobacco industry influence and protecting their public health policies from commercial and vested interests, Oman scored 16th with a score of 47 in the global tobacco index, Figure 3²⁴. More action is required to ensure the implementation of Article 5.3, and this should be done as part of comprehensive tobacco control measures that address both demand reduction and supply reduction measures.

Figure 3.Global tobacco index indicators in Oman. The lower the score the better the index Source: Globaltobaccoindex, 24.

The tobacco tax system in Oman is a combination of import duty, excise tax, and value-added tax ²¹. Nonetheless, the total taxes account for 63% of the total retail price, which is less than the WHO FCTC's recommendation of having taxes cover at least 75% of the total retail price ²⁷. There has been a dro p in the trend of tax revenues since 2016 ²⁷, for unknown reasons. Tobacco imported into the northern governorate of Musandam is exempt from tax by royal decree, but an administrative fee of 1% ad valorem is levied ²⁷. This may undermine the impact of the tobacco tax and create opportunities for a potential illicit tobacco trade. However, the recent introduction of the stamp system for cigarettes can help combat illegal tobacco trading ²⁸. The revenues from the tobacco tax are not earmarked to fund initiatives aimed at preventing tobacco use or other health promotion initiatives ²⁷.

Smoking was outlawed at workplaces in Oman in 2008, followed by banning tobacco in enclosed public places in 2010 ²⁹. The existing smoke-free regulation allows for smoking and designated smoking areas within a non-smoking zone, both of which subject customers and staff to the dangers of second-hand smoke ²¹. The existing smoke-free regulation is not in keeping with the "best practice" approach recommended in FCTC Article 8, which calls for a completely smoke-free environment in enclosed public places.

Current epidemiological data revealed that a significant proportion of adults ^11.0% and children ^33.0% were exposed to second-hand smoke in enclosed public places ^{16, 20}. This clearly demonstrates the inadequate implementation of regulation in places covered by the smoke-free regulation. Furthermore, there is insufficient public health awareness of the health effects of second-hand smoke exposure, which hinders efforts to de-normalize smoking in both enclosed and outdoor public places. Furthermore, adults ^16.9% and children ^12.8% are both exposed to second-hand smoke at home ^{16, 20}. This indicated insufficient efforts, such as voluntary smoke-free initiatives, to safeguard the public against SHS in private places. Enacting a total smoke-free policy without exemption is the best practice for protecting the public from second-hand smoke. This will help to further de-normalize tobacco use, encourage people who smoke to consider quitting, and have broader environmental and community benefits ³⁰ .

The current tobacco content regulation governs the composition and emissions of different tobacco products ¹³, as well as the additives and flavours used in tobacco ^{18, 31}. However, there are several gaps that need to be addressed. First, there is no regular sampling or testing of the content and emissions of various tobacco products to ensure that the tobacco industry adheres to the standards ¹⁸. Without consistent tobacco content monitoring, the standard regulation can easily be violated. Second, the regulations governing flavours and additives permit the use of several chemicals that make tobacco products more appealing and addictive ³¹. This contradicts the FCTC recommendations for the prohibition or limitation of the use of chemicals and additives that make them more palatable, addictive, or give the false impression that they have health benefits ⁷. Third, there is no legal requirement for the disclosure of tobacco product information to the public or government authorities ^{21, 32}.

Health warnings on tobacco packaging are a cost-effective way to increase public awareness of the negative health consequences of tobacco use and reduce tobacco consumption ³³. The 2017 STEPS survey in Oman showed that almost one out of every two smokers considered quitting because of the warning label ²⁰. According to Article 11, the health warning message on tobacco packages and labelling should take up more than 50% but at least 30% of the main display space, preferably using a combination of culturally relevant text and pictorial warnings for maximum impact ³³. It is also recommended that the health warning message be periodically rotated, preferably every 12 to 36 months, to avoid message fatigue ³³.

The "Omani Standard for Packaging for Tobacco Products" was introduced in February 2023 ³⁴, replacing the previous 2001 national labelling regulation and the 2012 GCC Standardization Organization (GSO) Labelling of Tobacco Product Packs Act. The effectiveness of Plain Packaging is well established globally and can assist in reducing the appealing of tobacco products, making health-warning more effective, and removing misleading information on packaging ³⁵. The regulation sets standards for tobacco product labelling for all tobacco products and includes both pictorial and textual health warnings, along with advice to quit. Although the content of the health warning includes advice for quitting, it doesn’t include information on Quitline service or cessation support, probably due to the absence of cessation service on a national scale. There is no recommendation around the rotation of health warnings on packaging; instead, changes may be made if the public's interest so demands ¹⁸.

FCTC Parties have an obligation to educate, communicate with, and train people about the dangers of tobacco production, consumption, and exposure as part of the human right to health and education ³⁶. To accomplish the overall objective of tobacco control measures, the three pillars of training, communication, and education should be further developed and implemented as part of comprehensive tobacco control initiatives ³⁶. According to the STEPS survey 2017 statistics, 48.1% of adults observed anti-tobacco smoking information on television or radio, and 39.4% saw it in a newspaper or magazine in the last 30 days ²⁰. The 2016 GYTS survey showed two out of every three children ^65.0% saw or heard an anti-smoking media message on TV, radio, billboards, newspapers, or magazines ¹⁶. On the other hand, one in every three children^39.0% saw or heard an anti-tobacco message at a sporting event, a fair, or a community gathering ¹⁶.

Several gaps have been identified on this measure. First, there has been no recent mass media campaign in Oman to raise public health awareness about tobacco use and exposure ⁸. Furthermore, there is no data on incorporating the impact of tobacco use into medical or paramedical curricula as part of raising awareness among future healthcare personnel. Moreover, there is no credible resource addressing tobacco use and exposure in Oman. As the prevalence of initiation, current use, and second-hand smoke exposure rises, children and young adults’ merit special attention by directing public awareness activities to these vulnerable groups¹⁶.

Article 13 mandates Parties to implement a comprehensive ban on all forms of tobacco advertising, promotion, and sponsorship (“TAPS”) within five years of ratifying the FCTC ³⁷. To be effective, the ban must cover both domestic and cross-border advertising, promotion, and sponsorship. In Oman, TAPS is evident for both adults ²⁰ and children ¹⁶. According to the STEPS survey 2017, 10.2% of adults observed cigarette marketing in places where cigarettes are stored, and 7.0% noticed any cigarette promotion ²⁰. The GYTS 2016 revealed that TAPS was manifested in a variety of ways, including having items with cigarette brand logos ^10.4%, observing actors smoke while watching TV or films ^69.1%, seeing cigarette advertisements at points of sale ^34.6%, and being approached by a cigarette salesman for a free cigarette ^8.9%16. The tobacco industry is not prohibited from promoting itself through corporate social responsibilities such as sponsoring sporting events, providing training for children, and donating various health and educational equipment ²⁴. Additionally, the tobacco industry uses social media to advertise products, oppose policies, and build a positive public image³⁸. Some tactics used are to pay social media influencers to promote products discreetly. These tactics by the cigarette industry on social media violate cigarette marketing restrictions and interfere with health policy ³⁸. However, there is still a lack of understanding about the different tactics used by the tobacco industry to market or promote its products and improve its image. More efforts are required to close the identified gaps and reverse the pattern of tobacco use, particularly among vulnerable groups.

All forms of tobacco products are addictive ³⁹, making it essential to have an effective tobacco cessation programme to assist smokers in their attempts to quit. The benefits of quitting smoking can be seen both immediately and in the long run ⁴⁰. Brief advice, in the form of asking, advising, assessing, assisting, and arranging ^5As, from a healthcare professional can increase the quitting success rate by 30%, while intensive advice, including pharmacological and behavioural support, can increase the chance of quitting by 84% ⁴¹. According to FCTC Article 14, nations that ratify the WHO FCTC are required to offer tobacco addiction therapy ⁴². This can be done by incorporating tobacco dependence treatment into the nation's healthcare system ⁴². As a "best practice approach" to assisting people in quitting smoking, the WHO FCTC recommends that each tobacco control program incorporate at least three different forms of cessation treatments: pharmacotherapy, cessation counselling at a primary care system, and free Quitline.

According to the STEPS 2017 data, one in every two adults attempted to quit smoking in the previous year, and only one-third received smoking cessation advice from a healthcare provider ²⁰. There is no available data on the outcome of quit attempts. In Oman, there is no national tobacco cessation programme that satisfies the WHO FCTC minimum standard ²¹. The current tobacco cessation services are confined to primary health care settings, and they frequently face staffing and medication availability issues ¹². Brief advice is not routinely provided at each patient encounter. The healthcare system record (Al Shifa) does not maintain track of each patient's smoking status, nor does it have a specialized page where healthcare providers keep a record of smoking advice. Despite ongoing attempts to train doctors and nurses in smoking cessation, there is no clear strategy in place to train personnel from other disciplines or extend the service to secondary or tertiary care facilities. Incorporating a nationwide comprehensive tobacco cessation programme within comprehensive tobacco control initiatives can help smokers quit and reduce their risk of negative health impacts associated with tobacco use ⁴².

Article 15 of the FCTC recommends a licencing system for the sale of tobacco products in order to combat the illegal tobacco trade ²¹. However, Oman does not have a licencing system in place for the sale of tobacco products, making it easy to purchase tobacco products everywhere ¹⁸. Cross-border regulation remains challenging, especially in the free zone in Musandam, which may act as a gate for illicit tobacco trade ²⁷. In February 2023, a new tax stamp system was introduced in Oman, allowing customised digital stamps to be placed on manufactured cigarette products to monitor and track their movement from factory to consumer ²⁸. This system will prohibit the importation of manufactured tobacco products into Oman that do not bear effective tax stamps. Oman is yet to sign the Protocol on the Elimination of Illicit Tobacco Trade.

Article 16 requires Parties to prohibit the sale of tobacco products to and by minors ⁷. In Oman, the 2001 laws prohibit the sale of tobacco products to or by anyone under the age of 18 ¹⁸. However, data from the 2016 GYTS revealed that a large proportion of children were ever or current users, raising concerns about the degree of compliance with regulations that prohibit the sale of tobacco products to and by minors ¹⁶. There are no prohibitions on the sale of single cigarettes, vending machine sales, or internet sales, all of which make cigarettes more affordable and available to children and young generation ¹⁸. Additionally, the law does not require age verification at the point of sale before purchasing tobacco products. The sale of tobacco products is not restricted by location, which may foster the spread of tobacco sales near residential areas and other public areas where children and young adults congregate ⁴³. Restricting sales per location and imposing licencing system can further reduce the availability of tobacco products and thus reduce tobacco use. Some countries raise the legal smoking age from 18 to 21 years in order to reduce the accessibility of tobacco products to young people and further de-normalize tobacco and nicotine products ²³. This will further reduce the prevalence of tobacco use among children and adolescents and improve the current and future health and well-being.

Tobacco leaf cultivation occurs in extremely restricted regions of Oman, but no initiatives have been taken to give farmers financially viable alternatives to switching to other crops [21]. There is insufficient data to safeguard farmers and the environment from tobacco cultivation and tobacco products.

In accordance with Article 19 of the WHO FCTC, Parties shall consider taking legislative action or advancing their existing legislation, as appropriate, to deal with criminal and civil culpability, including adequate compensation ⁷. In Oman, there is no tobacco control law that contains measures for criminal responsibility for any violations of the tobacco control legislation, nor are there any tobacco-specific civil liability measures ²¹. No one had filed a criminal or civil liability action, including proper compensation, against any tobacco business with respect to any ill health effects caused by tobacco use.

According to Article 20, Parties are mandated to create national, regional, and international health monitoring systems, as well as to start, collaborate with, and support research on tobacco use and tobacco control initiatives ⁷. However, no national surveillance system has been established in Oman to track tobacco use and tobacco control initiatives. Oman has participated in international surveillance aimed at monitoring tobacco use, either as an independent tobacco survey (GYTS) or as part of larger international surveys that monitor other risk factors (STEPS survey). Four cycles of the GYTS have been conducted in Oman, the most recent in 2016. Adult tobacco use was last measured in 2017 as part of the national STEPS survey.

Data showed that adult tobacco use is increasing, but no additional efforts have been made to investigate the sociodemographic and health-related features of tobacco users or to estimate the health consequences of tobacco use. Similarly, the 2016 GYTS revealed that a significant proportion of children were either regular or ever tobacco users; however, there is no recent data to compare with. Establishing a nationwide tobacco control surveillance and monitoring system that monitors tobacco use and ‘the effectiveness of tobacco control policies on a regular basis helps to identify and address the gap in tobacco control measures. Allocating a certain portion of the tobacco control effort budget to monitoring and surveillance systems contributes to the progress of tobacco control initiatives.

Table 2 summarises the gaps in different FCTC measures in Oman. Overall, there is only partial implementation of various FCTC measures, which is primarily due to the lack of comprehensive national tobacco control legislation that aims to advance the implementation of the Convention at best practice and aid in monitoring and enforcing its various measures.