Background:
Despite knowledge of harms, smoking rates remain high and continue to rise in Middle Eastern Countries. Initiatives such as the FCTC were developed to address the tobacco epidemic through health policy. Despite its positive impact, implementation remains a challenge. In this study, we assess compliance of labelling on tobacco packets from twelve Middle Eastern countries with national legislation and FCTC recommendations.

Methods:
Investigators from twelve Middle Eastern Countries collected at least 10 unique packets of the most commonly consumed and cheapest brands of cigarettes between January 2015 and November 2016. The countries included Bahrain, Israel, Kuwait, Oman, Qatar, Saudi Arabia, United Arab Emirates (High-Income Countries - HIC), Jordan, Lebanon, Turkey (Upper-Middle Income Countries - UMIC), Egypt, and Palestine (Low-Middle-Income Countries - LMIC). A total of 140 packets were inspected using a structured data collection tool; all labels were assessed for content, size, and location.

Results:
Health Warnings were present on the Principal Display Area (PDA - front and back panel) on 98% of packets. All countries except for Palestine met or exceeded the WHO minimum recommendations that 30% of the packets PDA should be covered by a health warning label. However, only Bahrain, Israel, Kuwait, Qatar, and Turkey met their own national legislation about the minimum area of the packets PDA that must be covered by a health warning label.
Promotional labels were present on all packages. Deceptive terms such as 'light' and 'blue' were found on 55% of all packs.

Conclusions:
Most countries were compliant with WHO recommendations on health warning labelling. However, there is poor compliance and implementation of national legislation in these countries. Promotional and deceptive labelling were present on packets from all countries despite being banned accordingly to WHO recommendations and national legislation. Monitoring labelling on tobacco packets with country-specific feedback may help improve compliance and implementation.