Navigating Obstacles To Tobacco Harm Reduction Efforts In Africa

On December 9, 2022

SMOKING prevalence is relatively low on the African continent despite projections by the World Health Organisation (WHO) that the total number of tobacco users in Africa will increase to 62 million of whom 51 million will be smoking combustible tobacco by the year 2025. This increase will largely be driven by an envisaged population growth. Overall smoking rates in Africa are low by international comparisons, with a prevalence of 8.4 percent across the continent.

The estimated number of people who die each year due to tobacco smoking in the region is 205,857, accounting for 2.3 percent of all deaths (2022 Global State of Tobacco Harm Reduction). While these figures might paint a gloomy picture, the situation on the ground presents a huge opportunity for Tobacco Harm Reduction (THR) efforts on the African continent where the need for appropriate, accessible and affordable safer nicotine products (SNP), supported by evidence-based product regulation cannot be overemphasized.

In as much as Tobacco Harm Reduction opportunities are many, a myriad of Obstacles stand in the way of adoption of Safer Nicotine Products and implementation of Tobacco Harm Reduction in Sub-Saharan Africa. For example the lack of affordable, acceptable and appropriate safer nicotine products. The availability and accessibility of safer nicotine products like electronic cigarettes, Heated Tobacco Products (HTP) and Nicotine Replacement Therapies (NRT) remain poor in many Low Middle Income Countries (LMIC). Where available, the products are limited in supply and their prices are too high for an average smoker.

Speaking at the Second edition of the Harm Reduction Exchange in Nairobi, Public Health Specialist, Dr Vivian Manyeki said even though Harm Reduction interventions are underway in Africa, more still needed to be done to navigate the challenges standing in the way of harm reduction on the continent.

“We might want to ask, where are all these cigarette forms coming from? Where all these forms of drugs and alcohol coming from and what is it that can be done about these people who are using be it these substances. What does  it entail to take someone from regularly using drugs to a point of being clean? We can do more policy wise by bringing in the legislators into the room for the conversation and even just training people,” said Dr Maneyki.

Apart from unavailability, inaccessibility and acceptability of tobacco harm reduction products in Africa, the region is also riddled with a weak healthcare systems due to underfunding and neglect as some governments are unable to meet the basic requirements for a good healthcare system. Smokers in the sub-Saharan region also experience difficulty in accessing smoking cessation support, including NRT. In addition, NRT products can be expensive or, in many cases, non-existent. People with mental health problems and substance use issues are likely to be heavy smokers.  However, national mental health policies in many countries in the region do not directly address smoking in these populations.

“Many smokers are unable, or at least unwilling, to achieve cessation through complete nicotine and tobacco abstinence. They continue smoking despite the very real and obvious adverse health consequences and against the multiple public health campaigns. Conventional smoking cessation proposals should be complemented with alternative but more realistic options through Harm Reduction.”

Africa’s healthcare has of late been heavily dependant on donor and external financing and this according to Tobacco Harm Reduction experts has also weighed down efforts to implement effective harm reduction programs on the African continent. Due to limited resources experienced in many African countries, there is a heavy reliance on the World Health Organisation’s (WHO) recommendations. Governments often ignore the science and the evidence. For example, Uganda, Mauritius, Seychelles and Ethiopia all hurried to ban the sale of electronic cigarettes, as advised by the WHO, without consulting consumers or examining the likely effects of such a policy.

Widespread and deliberate misinformation about reduced risk nicotine products is pushed by organisations in the region funded by the US-based NGO Campaign for Tobacco Free Kids (CTFK), itself a beneficiary of money from Bloomberg Philanthropies which funds much of the WHO’s tobacco control work. Anti-Tobacco Network Botswana, National Council against Smoking in South Africa, Kenya Tobacco Control Alliance and Mathiwos Wondu Ye-Ethiopia Cancer Society are all CTFK beneficiaries that have turned the war against smoking into a war against nicotine.

The lack of awareness of THR has also slowed down harm reduction in Africa. Many consumers, healthcare institutions and governments in Sub-Saharan Africa are unaware of tobacco harm reduction. This lack of knowledge means that consumers and stakeholders often make uninformed decisions regarding personal and public health.

“The unavailability of affordable, accessible and safer nicotine products might open room for substandard products that will be sold on the streets,” said Amadou Mahtar Ba, a media leader.

Progress in Africa is also hampered by misinformation. SNP such as nicotine vaping products and heated tobacco products are mainly tailored to, and affordable for, smokers in higher income countries and richer groups in LMIC.

Tobacco Harm Reduction in Africa comes at a time that a number of African countries have taken up tobacco leaf growing as a major business and foreign currency earner.

In 1995, Zimbabwe and Malawi were the only major tobacco leaf growing countries in Africa, but since then, many others have significantly increased production. By 2012, the largest tobacco leaf producers were Zimbabwe (25.9 percent of Africa’s output), Zambia (16.4 percent), Tanzania (14.4 percent), Malawi (13.3 percent) and Mozambique (12.9 percent).

In 2018, Africa produced 722,187 tonnes of tobacco leaf, representing 11.4 percent of total global production, with Sub-Saharan Africa being the principal source (around 90 percent). This poses a great threat to Tobacco Harm Reduction interventions on the continent as players and producers of tobacco leaf see THR as a direct threat to their source of income. Tobacco is an important source of revenue, for example, in 2018, Malawi exported tobacco leaf worth US$529 million, representing 8.5 percent of the country’s Gross Domestic Product (GDP) that year.

Tobacco control is another hindrance to Tobacco Harm Reduction in Africa. Only five of the 48 countries in the region (Eritrea, Malawi, Mozambique, Somalia and Sudan) have not ratified the WHO’s Framework Convention on Tobacco Control.

Joseph Magero, chairman of Campaign for Safer Alternatives said safer nicotine products were being met by hostility from public health and regulatory authorities and this has led to the slow uptake of Tobacco Harm Reduction Initiatives in some of the continent.

“Thousands of people are dying in Africa due to the ignorance of some African governments. We have several products that can be used to reduce the harm of tobacco by using vaping, snus and e-cigarettes. Unfortunately, the products are not easily found in Africa and where they are found are expensive,” said Magero.

Meanwhile, Chimwemwe Ngoma, a media professional and communicator from Malawi said there was lack of scientific research around harm reduction in Africa.

“There is a lot of misinformation on safer nicotine products including electronic cigarette use. In some cases, it is propelled by health authorities and some government officials who don’t really understand what tobacco harm reduction is.

“There is also a general lack of socio and scientific research on tobacco harm reduction on the African continent. Such kind of research should be driving policy and regulation on the continent. Unfortunately, some who have tried have already fallen into some trouble with regulatory authorities and this has led to bans on safer nicotine products and prohibitive policies being effected,” said Ngoma.