Tobacco advertisement, promotion and sponsorship in Arabic media between 2017 and 2019

Abstract

Nineteen out of 22 countries in the Eastern Mediterranean region, including the Gulf Cooperation Council countries, have ratified the World Health Organization Framework Convention on Tobacco Control (FCTC) treaty. One of FCTC’s provisions prohibits tobacco advertisement, promotion and sponsorship (TAPS). The TAPS provision requires nations to ban direct and indirect tobacco ads in media, as exposure to tobacco use in the media encourages smoking initiation. A limited number of studies have examined TAPS in Arabic media. This study examined the occurrence of tobacco use across Arabic television (TV) series released between January 2017 and December 2019 to assess compliance with the FCTC provision banning TAPS. The content analysis examined incidents of tobacco use in Arabic TV series, types of tobacco products used and the portrayal of second-hand smoking exposure. Out of 92 Arabic TV series (2952 episodes), there were 32 044 incidents of tobacco use. Incidents of tobacco use per episode fluctuated over time. During Ramadan, the median number of tobacco incidents declined from 6 in 2017 to 3 in 2019; however, it increased to 8 in 2018. Regular cigarettes and water pipes were the most common tobacco products used in TV series. While 27% of tobacco use showed characters who smoked tobacco products alone, 13% of the incidents portrayed characters who were smoking in the presence of children. This study concludes that tobacco imagery is not completely banned in Arabic media and its continued representation weakens tobacco control measures.

Introduction

Globally, 19% of the world population uses tobacco and 80% of users live in middle- and low-income countries (World Health Organization, 2019a). The World Health Organization (WHO) projects a decline in tobacco use prevalence from 20.5% in 2015 to 17% in 2025 in the Eastern Mediterranean region¹ (Tobacco Tactics, 2020; World Health Organization, 2022). However, population growth in the Eastern Mediterranean region creates more tobacco users, estimated at 90 million in 2015 to 94 million in 2025 (Tobacco Tactics, 2020; World Health Organization, 2019b). In the Eastern Mediterranean region, 14.2% of youth who have never used tobacco were susceptible to initiating tobacco use (Veeranki et al., 2014). Susceptibility, which is defined as the self-reported intention to initiate tobacco use, in the region is 2 percent points higher than the susceptibility measured among youth worldwide (Veeranki et al., 2014).

The Gulf Cooperation Council (GCC) is located within the Eastern Mediterranean region and consists of six political and economic partners: Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the United Arab Emirates (UAE). Although other Eastern Mediterranean countries share geographical borders and cultural characteristics, the GCC countries share a common heritage and experienced similar patterns of urbanization and economic growth due to the development of a petroleum export economy beginning in the 1970s (Mamtani and Lowenfels, 2018). The overall projected trend of tobacco use among adults in the GCC countries indicates a slight decline from 24.6% in 2000 to 22.1% by 2025 (World Health Organization, 2018; Fouad et al., 2021). Yet, within specific countries, projections for adult male tobacco smoking showed a slight increase in Oman from 13.6% in 2000 to 17.3% by 2025 (Fouad et al., 2021). Similarly, the projected trend of Saudi Arabia is expected to increase from 23.3% in 2000 to 25.4% by 2025 (Fouad et al., 2021). While the prevalence of cigarette smoking among youth has declined over time in Bahrain, Oman and the UAE, it has increased in Kuwait, Qatar and Saudi Arabia (World Health Organization, 2021). Susceptibility to initiating tobacco use among youth has increased in all GCC countries, except Bahrain, between 2001 and 2018 (Centers for Disease Control and Prevention, 2021).

The depiction of tobacco use in the media is significantly associated with susceptibility to tobacco use among youth, regardless of their gender, socioeconomic status, parents’ and friends’ smoking status and tendency towards rebelliousness and sensation-seeking (Sargent et al., 2002). A dose–response relationship between susceptibility to initiating tobacco use and exposure to tobacco in media was found in Australia, the UK and the USA (Charlesworth and Glantz, 2006). For instance, exposure to >50 incidents of tobacco use in media was associated with increased susceptibility to tobacco use among teens who had never used tobacco compared to those exposed to less than 50 incidents (Sargent et al., 2002). Media productions, such as television (TV) shows and movies, may not directly advertise tobacco but they implicitly influence the use of tobacco by presenting scenes of celebrities using tobacco products (Charlesworth and Glantz, 2006).

By August 2010, 19 out of 22 countries in the Eastern Mediterranean region, including the GCC countries, had ratified the WHO Framework Convention on Tobacco Control (FCTC) treaty to counter tobacco use (Al-Lawati and Mackay, 2020; World Health Organization, 2003). The FCTC includes several evidence-based policies to reduce the demand and supply of tobacco. Article 13 includes a direct and indirect ban on tobacco advertisement, promotion and sponsorship (TAPS) that should be implemented within 5 years (World Health Organization, 2015). The guideline for implementing Article 13 considers tobacco depiction in any form of media, such as films, magazines and TV shows, to be tobacco advertising and recommends that

Parties should take particular measures concerning the depiction of tobacco in entertainment media products, including requiring certification that no benefits have been received for any tobacco depictions, prohibiting the use of identifiable tobacco brands or imagery, requiring anti-tobacco advertisements and implementing a ratings or classification system that takes tobacco depictions into account (World Health Organization, 2015; 2008).

Despite this, 10 years later, all GCC countries, except Oman, reported that they have not had any restrictions on tobacco ads in media (Monshi and Ibrahim, 2021). All GCC countries, except Oman and UAE, developed a cooperation plan with other nations to eliminate cross-border advertisement of tobacco (World Health Organization, 2020). However, only Bahrain has imposed penalties such as fines, corrective advertising remedies and licence suspension and/or cancellation for cross-border tobacco advertisement (World Health Organization, 2020). All GCC countries enacted tobacco control laws based on the FCTC treaty at the national level, most of which state that domestic TV and radio are required to ban tobacco advertisement (Tobacco Control Laws, 2019). The laws also indicate several sanctions, including fines and/or jail for breaking the provision related to banning tobacco ads in domestic media (Tobacco Control Laws, 2019).

Several reports released by public health agencies in the Arab world discussed the occurrence of tobacco use in Arabic media (El-Awa et al., 2018; World Health Organization, 2005). In 2018, El-Awa and her peers called for examining tobacco imagery in media to inform policymakers and improve the implementation of tobacco control policies in the Eastern Mediterranean region (El-Awa et al., 2018), but no study assessed the extent of the tobacco imagery problem in media. While data related to tobacco imagery in media in several countries such as the USA and India are available (Tynan et al., 2019; Arora et al., 2020), there is inadequate research examining tobacco imagery in the Middle East media. This study was developed to fill that gap and examine the occurrence of tobacco use in Arabic TV series released between January 2017 and December 2019 in the context of the FCTC provision that bans TAPS.

Method

Data sources

We used the IMDb database (http://www.imdb.com) to identify Arabic TV series (IMDB, 2021). This database contains information related to cinema, TV programmes and video games. Information includes the types of production (i.e. films, TV series, documentaries, etc.), country, language, release date, genre, run time and rating (IMDB, 2021).

Inclusion and exclusion criteria

Only TV series were rated in this study. The eligibility criteria were determined based on the countries that produced the TV series, language spoken in the TV series, the time when the TV series were released and broadcast channels. In the IMDb, specific keywords and terms were used to search for the TV series, including Title Type (‘TV series’), Release Date (‘1 January 2017’ to ‘31 December 2019’), Countries (‘Bahrain’ ‘Egypt’ ‘Iraq’ ‘Jordan’ ‘Kuwait’ ‘Lebanon’ ‘Oman’ ‘Palestine’ ‘Qatar’ ‘Saudi Arabia’ ‘Syria’ ‘United Arab Emirates’ ‘Yemen’) and Language (‘Arabic’). Beyond the parameters of geographic location and time frame, no other restrictions in the search were applied. All genres of Arabic TV series released between 1 January 2017 and 31 December 2019 were included. The rationale behind selecting these countries was that they share the same language and dialect (Zaidan and Callison-Burch, 2014). The purpose of choosing this time frame was to rate recent TV series for three consecutive years; however, the year 2020 was excluded to avoid any changes in media streaming that may have resulted due to the Coronavirus Disease 2019 (COVID-19) pandemic.

Viewership in the Middle East region increases during Ramadan, which is the ninth month in the Islamic calendar and when Muslims fast from dawn to sunset as a form of religious practice (Deane, 2009). Therefore, TV series produced during Ramadan within the study time frame were labelled. Due to the negative impact of the COVID-19 pandemic on the media and entertainment industry, the year 2020 was excluded. Talk shows, reality TV, game shows and documentary TV programmes were also excluded because they are not that popular in the Middle East (Dubai Press Club, 2020). If TV series have multiple seasons, only seasons that were released in the given time frame were included.

TV series were obtained from three widely broadcast networks in Arab countries: MBC channels, Dubai channels and Abu Dhabi Media channels (Dubai Press Club, 2020). These channels also offer a streaming (on-demand) service that allows viewers to watch TV programmes online. If the TV series is available on multiple networks, the following priority will be applied: (1) MBC channels, (2) Dubai channels and (3) Abu Dhabi Media channels. TV series not broadcasted on the considered channels were not included in the study (Figure 1). The initial search in the IMDb database yielded 209 TV series; of these 12 were duplicates, 26 did not meet the eligibility criteria and 79 were not found in the three considered channels. The final number of TV series included in the study was 92.

Data collection

Four coders collected data. Besides the main investigator, three coders were hired to conduct qualitative coding. A professional producer/director was consulted prior to data collection. He helped search the IMDb database, explain key terms related to cinema and TV series and demonstrate common casting techniques to facilitate data collection. Training sessions and hands-on practice were provided for coders over 2 days. Hands-on practice consisted of watching and coding for selected episodes to ensure that coders were able to use the codebook (further information about the codebook can be submitted upon request). Coders were given formatted excel sheets to recode data along with the codebook. IBM SPSS Statistics 27 software was used to randomly assign TV series to coders and each TV series was coded by two different coders (IBM Corp, 2020). Before allowing coders to initiate the coding process, 10% of the TV series were randomly assigned and coded from 15 November 2020 to 10 December 2020 to assess coding quality. As a result, the codebook was amended. Data collection was completed across 4 months, from 5 January 2021 to 10 April 2021. Due to COVID-19 social distancing and lockdown in Saudi Arabia, coders reported that they had more time to watch the assigned TV series at home.

Measurement

The primary outcome was to track the incidents of tobacco use in TV series; incidents were defined according to Thumb Up! Thumb Down! (TUTD) method, a validated method created by Breathe California (Breathe California, 2020). The TUTD method consists of seven criteria to capture the occurrence of tobacco in media (Figure 2) (Arora et al., 2020; Breathe California, 2020; Glantz et al., 2012; Rath et al., 2020; Cullen et al., 2011). Incidents of tobacco use were defined as actual use or implied use of tobacco by a character in a TV series. The secondary outcomes were to assess (1) common tobacco products used and (2) second-hand smoking (SHS) exposure in TV series. The codebook of this study was developed based on the criteria of the TUTD method. Additional variables were also used to capture tobacco product brands and SHS exposure in TV series.

In addition to the multiple tobacco products coded in this study, the smoking of illicit substances such as cannabis and/or marijuana was counted separately from tobacco use (Figure 2). This approach was taken to reduce the over/underestimation of tobacco use, as cannabis/marijuana use is common in Arabic media (Egypt today, 2018; El Kazdouh et al., 2018). According to the TUTD method, any forms of tobacco signs or cues, such as ashtrays, tobacco on billboards and/or signs on common items, were not counted in this study. Exposure to SHS in the TV series indicated whether the character was smoking alone or with others and thus exposing others to smoking (Figure 2).

Data analysis

We used descriptive statistics to report the main characteristics of the TV series included in the study, as well as tobacco use imagery. Reliability was assessed using the intra-class correlation coefficient (ICC). The ICC is a measure used to assess agreement across coders where the ICC value of 1 indicates perfect agreement, while 0 indicates complete disagreement. The ICC values between 0.75 and 1.0 were determined as excellent agreement (Hallgren, 2012). The total incidents of tobacco use for each episode were calculated; then, inter-rater reliability was performed. After resolving the disagreement of 1% of the sample, a significant inter-rater agreement was reached (ICC ≥ 0.8). The analysis was performed using IBM SPSS Statistics 27 software (IBM Corp, 2020).

Results

There were 92 TV series examined in this study, which accounted for 2952 episodes. The average number of episodes in each TV series is 32.1. The runtime for each episode is about 40 min, and ∼1925 total hours of media were rated. Only one TV series had two seasons included as two independent TV series. Egypt produced the highest number of TV series. More than 50% of the TV series were released during Ramadan and broadcast on the MBC channel. Only 20.6% of TV series had age ratings. Most of the TV series were in the genre of drama while other genres such as comedy, action and mystery constituted a smaller percentage (Table 1; Supplementary Appendix1: Details of TV series analysed in this study).

Incidents of tobacco use

Of the 2952 episodes watched, 60.6% of the episodes have incidents of tobacco use. Incidents of tobacco per episode differ by the produced country (Figure 3). A total of 32 084 incidents were found in the TV series (Range: 0–151 per episode). The occurrence of tobacco use per episode fluctuated over time (Figure 4). During Ramadan, the median number of tobacco incidents decreased from 6 in 2017 to 3 in 2019, while it peaked at 8 in 2018. Although there were no incidents of tobacco use in TV series produced by Kuwait and Saudi Arabia in 2017, there were about 458 incidents of tobacco use in TV series that aired in 2018 and 2019. The total incidents in age-rated TV series were 7905 (Range: 0–138 per episode). The median number of incidents per episode in age-rated TV series was 8, while it was 2 in non-age-rated TV series. The median number of tobacco incidents in age-rated TV series slightly decreased from 9 in 2017 to 6 in 2019 (Figure 5).

Common tobacco products

Several types of tobacco products were recorded. Twenty-four per cent of incidents showed regular cigarettes, 22% water pipes, 13% cigars, 6% pipes and 3% electronic cigarettes. Approximately 15% of tobacco use had at least one incident where characters were observed smoking either tobacco mixed with substances or pure cannabis in the form of a cigarette or water pipe. Seventeen per cent of incidents showed a cigarette carton (Figure 6a). TV series produced in Egypt, Lebanon and Syria contained all types of tobacco products while TV series produced by Kuwait and Saudi Arabia had only regular cigarettes and water pipes. Various tobacco brands were recorded in at least 11 TV series. Tobacco brands included L&M, Marlboro, Merit, Pall Mall and Parliament (Figure 6b).

Second-hand smoke exposure

Twenty-seven per cent of the total number of incidents of tobacco use in the TV series showed character/s who smoked tobacco products alone. Thirty per cent of incidents showed character/s who smoked tobacco with adults who were not smoking in the same scene. Similarly, 30% of tobacco use included character/s who smoked tobacco products in the company of other smokers. In addition, 13% of the incidents showed character/s who smoked in presence of children (Figure 7); however, this observation has declined over time. Five TV series (9.1%) which contained character/s smoking in presence of children had an age rating.

Discussion

This study is the first to examine the occurrence of tobacco use in Arabic media. The initial goal of this study was to examine the occurrence of tobacco use in TV series produced by GCC countries and to assess whether media productions have complied with FCTC provisions in practice. However, the media and entertainment industry is still developing in the GCC countries, so the leading productions are found in neighbouring Arab countries such as Egypt, Syria and Lebanon (Dubai Press Club, 2020; Allam, 2019). The expansion of satellite channels has made TV series easily accessible across geographic areas and not limited to the country in which it was produced (El-Awa et al., 2018), especially among Middle Eastern countries where people speak Arabic and similar dialects (Zaidan and Callison-Burch, 2014).

All TV series in this study were produced after the ratification of the FCTC treaty (United Nations, 2020). However, study findings revealed that on-screen tobacco use is not completely banned in several countries. These findings suggest a gap in implementing and enforcing Article 13 of the FCTC. The tobacco imagery in media requires active enforcement and collaboration across agencies to ensure adherence to the law. Lessons learned could be taken from India, where stakeholders, the governmental sector and civil society advocacy groups have worked together to ensure compliance with provisions to prevent tobacco imagery in media. In addition, India developed static health warnings shown during the display of tobacco use in media and applied strict editorial justifications. As a result, India reduced 41% of tobacco imagery in movies over 10 years (Yadav and Glantz, 2021). Therefore, GCC countries should raise public awareness about the negative impact of on-screen tobacco use. They should also dedicate more efforts to engaging stakeholders and tobacco control advocacy groups to encounter media industry activities related to on-screen tobacco use.

In this study, we shed light on the incidents of tobacco use in more than 80% of TV series that were broadcast during Ramadan. The problem of tobacco imagery in Arabic media takes a cultural turn since most of the TV series are produced during Ramadan (El-Awa et al., 2018). The media and entertainment industry competes to produce the best Arabic TV series during Ramadan to meet the desires of Arab viewers who watch TV series with family members after they break their fast at sunset (Parolin, 2019). As previous studies have indicated that the occurrence of tobacco use in TV series leads to immediate use of tobacco among regular smokers (Shmueli et al., 2010; Ismail et al., 2016), the high intensity of tobacco imagery during Ramadan may be associated with increased tobacco consumption, hinder anti-tobacco efforts that intend to encourage smoking cessation during Ramadan and send the message linking tobacco use with relaxation and social gathering (El-Awa et al., 2018; Shadel et al., 2010).

The findings of this study also suggest that media normalizes exposure to SHS. More than half of the TV series contained scenes in which actors were smoking in the presence of non-smokers. Thirty-eight per cent of children, 25% of women and 24% of men are exposed to SHS in the Eastern Mediterranean region (Oberg et al., 2011). As of 2016, an estimated 42.6 individuals, who smoke in the Middle East and North Africa, were responsible for one individual who died due to exposure to SHS (Yousuf et al., 2020). Scenes that normalize SHS on TV series weaken the implementation of smoke-free policies in the region, and thereby weaken progress towards FCTC goals. Middle Eastern non-smokers are more tolerant to SHS exposure and seek no individual rights to protect themselves from SHS (Hammond and White, 2001). Thus, stakeholders should take collective action to de-normalize SHS and counter the tobacco industry. For example, the government should develop tobacco control policies that preserve the rights of non-smokers and ensure that media are smoke-free. Scholars should examine the effectiveness of these tobacco control policies within specific contexts to support decisions made by policymakers. Tobacco control advocacy groups, schools and parents play an essential role in influencing the decision-making process and support the implementation of tobacco control policies (Weishaar et al., 2016).

This study showed the lack of age rating in Arabic media productions, as only 19 (20.6%) of the TV series included in this study have age ratings. The Motion Picture Association of America (MPAA), which is a trade association that represents film production companies, helped develop an age-rating system to inform parents of whether the show contains inappropriate content for children (Motion Picture Association of America, 2021). However, the MPAA age rating is a voluntary practice (Motion Picture Association of America, 2021). Examining the impact of the MPAA age rating on tobacco use revealed that the (R) rating² could decrease smoking onset by 18% in the USA (Sargent et al., 2012), but there is limited guidance for parents to monitor media content that contains tobacco use (Cox et al., 2018). Regulatory agencies in the Eastern Mediterranean region should enhance the use of standardized age rating and tobacco descriptors (under age 18 is recommended for shows with tobacco use), so viewers can make an informed decision when watching media (World Health Organization, 2015).

The study revealed several imported tobacco brands being advertised in Arabic TV series. Aligned with the study findings, historical documents from the tobacco industry show how the industry used tobacco product placement in Hollywood movies to advertise for tobacco brands (Shields et al., 1999). Tobacco companies rely on increasing the display of tobacco in Arabic media, such as Egyptian and Lebanese media (Hammond and White, 2001; White and Hammond, 2001). One of the examples of the tobacco industry’s interference in media is the co-sponsorship of the Cairo Film Festival in 1987 by Phillips Morris International, which awarded the winners and gave gifts to the attendees (PM-EEMA P-EA, F, 1990). While the tobacco industry has continued its efforts to weaken the ban on tobacco advertisement in Egypt and lobby political figures, including Egyptian Members of Parliament (Hammond and White, 2001; White and Hammond, 2001), it has started to face challenges in advertising tobacco brands in the Gulf media after the ratification of FCTC by GCC countries (Monshi and Ibrahim, 2021). Multinational cooperation is needed to eliminate tobacco imagery in Arabic media. Arab countries should adhere to the FCTC provisions and create binding agreements to restrict tobacco use in media and limit any interference from tobacco companies.

Limitations

The study has several limitations. Although the study examined a large number of TV series, the popularity and viewership of these TV series are unknown; especially viewership by young people. This study did not support the dose–response relationship between exposure to tobacco imagery in media and tobacco use. It is possible that TV series that contain high incidents of tobacco use are less popular among viewers or vice versa. Due to the lack of a publicly available viewership database, we utilized a systematic search approach in the IMDb database to obtain the Arabic TV series. However, youth in the Middle East have become more open to watching foreign media and web series that are presented on streaming platforms. Therefore, TV series included in this study may not represent popular and preferred series among youth. Future research should examine popular series among youth and assess the relationship between exposure to on-screen tobacco use and tobacco use in the Arab world, taking into consideration the role of several factors that impact this relationship such as age, gender, income and families and peers’ smoking status.

Conclusion

Although GCC countries that ratified the FCTC treaty are required to ban all forms of TAPS, most Arabic entertainment media productions have not complied with this regulation. With the increased use of online media platforms, the younger generations, which represent the largest segment of media consumers (Dennis et al., 2019), are at higher risk of exposure to on-screen tobacco use (Liang et al., 2015). The problem of tobacco use is associated with geographical and social characteristics; thus, a solution requires multinational cooperation to enhance the implementation of the FCTC measures. Moreover, it is critical to have community engagement and public–private partnerships to protect youth from experimentation and addiction to tobacco products, given that the private agencies create a large portion of the entertainment industry. As a result of these findings, governmental agencies, advocacy groups and policymakers should work with the media and entertainment industry to discontinue the occurrence of tobacco use in entertainment and adhere to a standardized age rating. The outcomes of preventing on-screen tobacco use in media are encouraging; therefore, GCC countries need to dedicate further efforts to eliminate the occurrence of tobacco use in Arabic media.

Supplementary data

Supplementary data are available at Health Policy and Planning online.

Data availability

Availability of data was mentioned here in the Method section of this article under Data source.

Funding

A financial aid was provided by Dr Jay Schinfeld to support for paying for the coders.

Acknowledgements

We would like to thank Dr Jay Schinfeld, who provided financial support in memory of his wife Sandy Schinfeld, a former PhD student in the College of Public Health at Temple University.

Author contributions

S.S.M., B.N.C., J.W. and J.K.I. conceptualized the study and provided critical revisions. S.S.M. and M.A.J.A. collected the data. S.S.M. analysed the data, interpreted the data and wrote the manuscript. All authors approved the final draft for publication.

Ethical approval

Ethical approval was waived by the institutional review board at Temple University (Protocol No. 26628).

Conflict of interest statement

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Reflexivity

It is essential to acknowledge that diverse authors conducted this research. The Middle Eastern background that S.S.M. and M.A.J.A. have helped understand the magnitude of the issue and develop the research question. On the other hand, expertise in tobacco use/control topic and research methods that B.N.C., J.W. and J.K.I. have helped in designing the study and interpreting the results. Collectively, the diverse research team helped in investigating the issue of tobacco use in media, taking into consideration the unique context of Arab countries.

Authorship

All authors are from high-income countries because this research is a part of S.S.M.’s doctoral dissertation. B.N.C., J.W. and J.K.I., who are professors in the USA, mentored S.S.M., who was a Saudi student (international student), during her education in the USA.

Endnotes

References