CAIRO, Egypt -- Offering a cigarette is as common as a handshake in Egypt, where the culture of smoking is so entrenched that patients sometimes light up in hospital rooms. But now the government is getting serious about the health risks, launching a new campaign of stark visual warnings about tobacco's dangers.
Starting Aug. 1, cigarette labels in Egypt will be required to carry images of the effects of smoking: a dying man in an oxygen mask, a coughing child and a limp cigarette symbolizing impotence.
It's a major step in Egypt's fledgling anti-smoking campaign and a dramatic change in a country where public discussion of smoking's health risks is nearly nonexistent.
"I would like to quit, but I just can't. But when you see pictures like this, like that sick man, that has an effect -- it does encourage you to stop," said Osama Sabri Mohammed, a 39-year-old civil servant puffing on a cigarette outside a government building in downtown Cairo.
The impotence message might have a particular effect on Egyptians, he said, because "they are really concerned about that."
The photo of the limp cigarette comes with the warning that "long-term smoking has an effect on marital relations" -- somewhat coyer than a version the European Union has recommended for its member countries, which states directly that smoking causes impotence and shows a discontented young couple sitting apart in bed.
Twelve countries, including Canada, Jordan, Brazil and Thailand, require graphic photos of the effects of smoking to be printed on cigarette packs -- and many have reported success in at least reminding smokers of the dangers.
But the campaign faces a tough challenge among Egypt's die-hard smokers.
Egypt is one of the top 15 smoking countries in the world: Nearly 60 percent of all adult males in the country of 79 million people use tobacco in some form, compared to 24 percent of men in the United States. An estimated 2 percent of Egyptian women smoke -- though most researchers believe female smoking is greatly underreported due to social taboos that push female smoking into private areas.
Smoking is widespread even among those supposed to know better: Nearly a third of male Egyptian health professionals smoke. In the hallways of the Health Ministry, "no smoking" signs are ubiquitous -- as are buckets of sand filled with cigarette butts from smokers ignoring the rule.
"Egypt is an extraordinarily challenging country because it has such a culture of smoking, it's so ingrained in day-to-day living," said Gary Saffitz, the deputy director of Johns Hopkins University's Bloomberg School of Public Health's Center for Communication Programs, which is helping Egypt with the campaign.
But, he says, the government appears to have realized the depth of the public health problem "not just in human capacity and lives, but the cost in dealing with all the disease generated by it."
While anti-smoking campaigns have been in place for decades in the West, the issue has not even been on the agenda in Egypt or across much of the broader Middle East. In the 1990s, when smoking in the developed world declined, it increased 8.6 percent in the Middle East, according to the American Cancer Society.
The first big step came in 2005, when Egypt ratified the World Health Organization's Framework Convention on Tobacco Control, which lays out methods to combat tobacco use, including pictorial warning labels.
Since then, the first baby steps have been taken to ban smoking in some areas. Airports and Cairo's metro are strictly no-smoking, and a 2007 law banned smoking in government buildings -- though enforcement is still an issue.
A month ago, the country's new tobacco control department was launched, though it consists of only two people in a closet-sized office with no telephones and an annual budget of just $12,500.
For the new label requirements, authorities field-tested a variety of images.
They found that warnings linking tobacco with death were not particularly effective with Egyptians, since dying is perceived as inevitable anyway. Also, images of diseased lungs left people confused about what was being shown.
Instead, the new warnings focus on threats to health and, particularly, to family, like the effect on children and pregnant women and the risk of impotence.
Numerous studies, including a 2003 report by Tulane University researchers, have found that smoking can be a major cause of erectile dysfunction, in part because smoking constricts veins and arteries, reducing blood flow.
"We need something to give the smokers a shock that they are in great danger," said Dr. Mohammed Mehrez, head of the tobacco control department.
There are many myths to overcome.
Some Egyptians are convinced only light cigarettes lead to impotence. Earlier this year, the state-owned manufacturer, Eastern Tobacco Company, voluntarily put pictures of diseased lungs on some packs -- but smokers just figured those packs were the ones that were harmful and switched to others, which some shopowners promptly started selling at a higher price.
And, as everywhere in the world, many smokers who realize it is bad still show scant interest in quitting.
"I've been smoking since I was 8 years old -- I used to pick up cigarette butts from the gutter and smoke them," laughed Hussein Hassan Mahmoud, a wizened 60-year-old butcher with one eye clouded from cataracts, sitting outside his Cairo shop enjoying a cigarette.
Mahmoud goes through three or four packs of the local Cleopatra cigarettes a day, at about 50 cents a pack, and he scoffed when shown the new warnings. "People will just tear the labels off."