In a time of great difficulty in Iraq, during which most coverage of it in the world’s media is dominated by security issues, it is easy not to realise that wherever possible, at least in the more secure areas, Iraqi people are trying to get on with their lives and work. For public health officials, this includes the formidable challenge of tobacco control which, due to the virtual absence of activity by the former regime, effectively means starting from scratch.

The Kurdish region, regarded as the most secure part of the country, has been a federal state within Iraq since October 2005. Five and a half million people live there, some 80% of them ethnic Kurds and 15% Arabs, a direct reversal of the proportions of ethnic groups for Iraq as a whole. Life expectancy at birth is 61.4 years for men and 64.9 for women; among the top five causes of mortality and morbidity are cardiovascular disease, cancer, respiratory disease, and hypertension, with smoking, unsurprisingly, a significant factor.

Current laws include a ban on smoking in all government buildings, but it is widely disregarded and smoking can be seen everywhere, from hospitals and health clinics to schools and administrative office buildings. Although tobacco advertising is banned on television and in mass media, most people have satellite televisions with access to channels from every country in the region, many of them still carrying tobacco advertising, emphasising the urgent need for regional collaboration. Meanwhile, there are still plenty of highly visible tobacco advertisements on billboards, especially giant ones beside main roads and in downtown areas of the cities, as well as in shops and tobacco vendors’ stands.

Even among the relatively low earning mass of the population, smoking is easily affordable. While a pack of Marlboro Lights is around US$2, much cheaper brands are the popular choice—around US$0.40c for brands imported from South Korea, for example. They are available all over the Kurdish region, freely sold to minors, and the low price is accounted for by the absence of any kind of duty or import tax. Water pipe smoking is also popular, especially among students and other young people of similar age, who generally believe it to be harmless. Water pipes are readily available in restaurants and internet cafés, accessible to the 70% of the population who live in urban areas.

In Iraq, there are plenty of highly visible tobacco advertisements on billboards.

As in any serious tobacco control programme, the regional government’s health ministry knows that baseline data is essential, and gathering this has occupied much of its initial efforts and resources. With collaboration and support from the World Health Organization and the US Office on Smoking and Health, three standardised surveys are already well advanced: the global youth tobacco and school personnel surveys, and the health professional survey, the latter conducted among third year students of medicine, dentistry, pharmacy, and nursing.

Meanwhile, the ministry sent an anonymous survey to 850 doctors in August, and the 95% response produced a wealth of useful information. Smoking prevalence was 18% among males, and 6% among females, with more than 90% of both smokers and non-smokers agreeing that smoking was harmful, and 98% of non-smokers and 52% of smokers also agreeing that it should be banned in hospitals and schools. However, it emerged that only 5% of doctors recommended their patients to stop smoking, with 96% pleading lack of training for this role, and a similar proportion noting that cessation pharmaceuticals were unavailable. The results only confirmed doctors as one of the health ministry tobacco control team’s top priority targets.

So far, knowledge about the smoking prevalence of the general population is less clear, at least for males. 1990 estimates put it at 40% for males and 5% for females, though a recent (May 2005) cervical cancer survey reported a figure of 8%, despite cultural and Muslim taboos on Kurdish women smoking. The confidential setting of the survey, by primary health care providers, means the result is likely to be accurate. As the region’s fortunes improve, the still large majority of non-smoking women are considered likely to become a target for tobacco manufacturers.

Among the many challenges facing the tobacco team is a lack of human resources: there are no professional or non-governmental organisations interested in helping. Just in time alone this is limiting—for example, all the survey work was carried out by doctors in the public health sector, often involving travel over considerable distances, some of it requiring roundabout routes to avoid less secure areas. The health ministry has appointed an official to be responsible for its programme, and two staff are currently being trained with assistance from Egyptian and US health institutes. As the programme proceeds from data gathering to the education of health professionals and the general public, each stage will no doubt identify additional tasks and decisions. Whether it be regional collaboration, radical revision of a medical syllabus unchanged over the last two to three decades, or the development of tobacco education materials (with the added work and expense of there being two main Kurdish dialects), every task will require staff input as well as the framework of an agreed policy.

There are many unknowns ahead—for example, how much has the long experience of war, insurgency, and the stress of living without electricity, and the many other hardships of the Kurdish region’s recent past, affected people’s smoking behaviour and attitudes? Can people be persuaded to try to stop smoking after living so long with not knowing what tomorrow will bring? And how difficult will it be to address passive smoking, when typical households comprise extended families where up to five adults smoke? It is an important issue, too, when the leading cause of mortality in children under 5 years old is respiratory disease.

The Kurdish region clearly faces a big challenge, but at least work has begun. The regional government will be sending delegates to the World Conference on Tobacco and Health in Washington DC next July. It is to be hoped that colleagues from all over the world will be interested in their experience, and that some will be able to offer support and continuing collaboration in return.