The state-owned tobacco monopoly in Lebanon: Insights for tobacco control

Abstract

Introduction

Tobacco use continues to present a major public health issue driving non-communicable disease (NCDs) and disproportionately impacts low- and middle-income countries (LMICs), like Lebanon. Lebanon offers a compelling case study for understanding the challenges LMICs face to advance tobacco control. These challenges include fragile economies; the entrenched influence of state-owned enterprises (SOEs); weak regulation; and political complexities. These challenges are present in Lebanon, where the tobacco market is characterised by four contextual factors: (a) state-owned tobacco monopoly (SOTM), a state owned tobacco industry that exercises monopoly control of the Lebanese tobacco market and is 100% owned by the government – it is known as the Regie Libanaise de Tabacs et Tombacs (referred to hereafter as the ‘Regie’ (a French word meaning government monopoly)); (b) an unusual product profile compared to high-income countries (HICs), including substantial prevalence of waterpipe tobacco smoking (WTS); (c) a market shaped by acute financial crises and chronic political instability; and (d) a state with a complex power-sharing political system.
Despite Lebanon’s ratification of the WHO Framework Convention on Tobacco Control (WHO FCTC), a global treaty to combat the tobacco epidemic, the country continues to suffer from a high public health burden created by the tobacco use epidemic and struggles to advance comprehensive tobacco control measures. The aim of this thesis is to understand these four contextual factors that influence the tobacco market in Lebanon and their implications for tobacco control. Understanding Lebanon’s contextual factors can provide critical insights into both the obstacles and opportunities for enhancing tobacco control measures not only in Lebanon, but also in other LMICs, especially those with a SOE.

Methods and findings

This thesis adopts the alternative format of four interconnected research papers of publishable quality, with each paper being based on the common case study of the Lebanese tobacco market. While each paper explores distinct aspects of the tobacco market, they collectively draw upon and investigate the interplay between the four contextual factors of the Lebanese tobacco market.
Data sources include both quantitative and qualitative data. Specific data sources for each paper are outlined below along with the research issue investigated and the findings of each paper.

Paper I: (published in BMC Public Health)

Tobacco control research has paid significant attention to monopoly-oriented Endgame models (MOEM), which are measures aimed at phasing out tobacco use through the mechanism of state monopoly control over national tobacco markets. To date, these debates have remained largely theoretical. Paper 1 considers what lessons could be learned by studying an existing SOTM, the Regie, despite the fact that its current mandate is not to phase out tobacco use but to sell tobacco on a commercial basis.
The paper undertakes qualitative document analysis based on online news articles from mainstream Lebanese newspapers and the Regie’s website, peer-reviewed academic studies, and grey literature. It examines the governance and operational remit of Lebanon's SOTM, considering the implications for tobacco Endgame proposals featuring a MOEM.
Findings identify the potential and pitfalls of adopting MOEM to end tobacco use. Specifically, the existing literature linked to the proposed MOEM approach: (i) does not seem to fully appreciate the extent to which the MOEM could end up acting like transnational tobacco companies; (ii) has only vaguely addressed the implications of political context; and (iii) does not address tobacco growing despite it being an important element of the supply chain in many countries.

Paper II: (published in Tobacco Control)

Waterpipe tobacco smoking (WTS) is frequently prevalent in LMICs, and this prevalence has been increasing over the past two decades. Yet, the current status of specific waterpipe tobacco policies globally remains understudied, making it difficult to inform tobacco control policies. Paper II examines how WTS control policies, is regulated at the global level, and their potential to advance tobacco control. By specifically investigating WTS control policies in countries with SOEs, this paper also contributes to understanding the potential of these WTS policies to advance tobacco Endgame strategies.
In doing so, Paper II reviews a wide range of WTS policies, primarily from the Campaign for Tobacco-Free Kids organisation’s Tobacco Control Laws website which acts as its main data source, to address questions around the regulation of WTS.
Findings indicate the number of countries with comprehensive WTS regulation has not changed since 2015. However, countries with a significant SOEs presence demonstrate stronger alignment with the WHO FCTC recommendations relative to those markets dominated by private tobacco companies.

Paper III: (under review at PLoS ONE, from where we have recently received positive reviewer comments and are currently attending to produce a revised version for resubmission there)

Economic crises occur across the globe, but LMICs are particularly vulnerable to their ill-effects. Such crises impact the affordability of all products, including cigarettes. The affordability of cigarettes is important because as cigarettes become less affordable people smoke less. However, during times of economic crisis, the affordability of all products are in flux simultaneously, making the relative affordability of cigarettes difficult to calculate. To date, this has yet to be explored in tobacco control research. Paper III assesses changes in the absolute and relative affordability of cigarettes in Lebanon following the 2019 economic crisis, including the Regie’s pricing strategies in response.
Quantitative data for Paper III was collected from publicly available resources on the websites of government institutions, including the Regie, to calculate and compare changes in cigarette affordability to changes in the affordability of a set of essential goods during the economic crisis. There is also a qualitative dimension to the study, in order to triangulate the findings and understand the pricing strategy. Data gathered from online news articles from mainstream Lebanese newspapers and the Regie’s website, peer-reviewed academic studies, and grey literature. This data is further supplemented with an original interview with the Regie.
Findings indicate that the price of cigarettes, as well as those of key food and non-food items, increased faster than overall inflation, making them less affordable. However, the fall in cigarette affordability was relatively weaker than that for food and non-food items, making cigarettes relatively more affordable compared to key expenditure items. This relative affordability can be attributed to the pricing strategies deployed by the Regie during the economic crisis, which strongly resembled those used by transnational tobacco companies (TTCs) in response to tax increases.

Paper IV: (draft in preparation for submission to Globalization & Health)

Article 5.3 of the WHO FCTC calls for state signatories to treat SOEs like other private enterprises when it comes to protecting health policy from industry influence. Yet these types of industry actors are clearly different in many ways and the implications of these differences for health policies, including for tobacco control, have not been explored in research to date. To further understanding of the similarities and differences between these different industry organisations, Paper IV focuses on the strategies deployed by the Regie to sustain its market during the economic crisis. During this challenging period, the Regie was forced to deploy a broad set of tactics to face this economic threat, offering an opportunity to document its practices and compare them to those deployed by TTCs, the latter of which are well-documented in the literature. Understanding these strategies is crucial for tobacco control advocates and policymakers, as SOEs like the Regie are likely to use similar tactics to counter market threats, including public health policies targeting unhealthy commodities.
Paper IV draws on data compiled from online news articles from mainstream Lebanese newspapers and the Regie’s website, peer-reviewed academic studies, and grey literature, coupled with data from interviews with a variety of industry and non-industry stakeholders.
Findings suggest that while SOEs often employ strategies similar to TTCs and other unhealthy commodity industries (UCIs), they also exhibit unique patterns of behaviour. This is influenced by the political-economic environments in which they are embedded, shaped by the distinctive expectations they face and access they enjoy as part of the state apparatus. Thus, there are important lessons for tobacco control in Lebanon, but also for other national tobacco markets dominated by SOEs.

Conclusion

There is a relative lack of attention paid to LMICs compared to HICs in tobacco control research, as well as disparities in the implementation and effectiveness of tobacco control measures. This thesis helps to develop a comprehensive understanding of the contextual factors in Lebanon that impede the implementation of effective tobacco control policies, with many of the findings also relevant to other LMICs facing similar contextual conditions.
The findings related to the four contextual factors of the Lebanese market demonstrate that: (a) while SOTMs behave similarly to TTCs during both normal and crisis times by putting profit before public health goals, they also pose some unique challenges for tobacco control due to the strategies they are able to deploy; (b) WTS is proliferating and remains relatively unregulated, undermining efforts to reduce tobacco use and suggesting the need for a global target to advance tobacco control; (c) economic crises and chronic political instability hinder prioritising tobacco control efforts as governments shift their attention towards more urgent and immediate needs, while the tobacco industry actively exploits the situation to expand its influence and protect its interests, exacerbating the burden of the tobacco epidemic; (d) in a complex power-sharing political system, SOEs often prioritise political interests over public health and even economic gain.
Overall, the findings demonstrate how the tobacco control community must remain mindful of how elements like organisational structure, mandate, and the political economy in which SOEs operate affect their specific behaviours, which should help in the development of policies and counterstrategies.
Collectively the findings across the four papers demonstrate the necessity of contextualised tobacco control in LMICs given the specific challenges they face. In such settings, systemic challenges often hinder global health goals. This suggests that LMICs may need policies specifically designed to directly address their particular needs

Date of Award	25 Jun 2025
Original language	English
Awarding Institution	University of Bath
Supervisor	Michael John Bloomfield (Supervisor), Rob Branston (Supervisor) & Lindsay Robertson (Supervisor)