The burden of tobacco use

Use of tobacco in the form of cigarettes and snuff is common in Africa. However, data on tobacco use prevalence in several countries in the Sub-Saharan African region is scarce. The most comprehensive global comparison of adult smoking rates suggests a smoking prevalence of 18% (28% among males and 8% among females) (1). Because smoking rates in the African region, especially among women, are considered to be relatively low compared to the more developed countries, the tobacco industry has turned its attention to the African region as its future growth market.

Tobacco use has been associated with increasing poverty especially in lower-income households, because the money that would have been spent by household heads on food and education is often spent to sustain the nicotine addiction (2). This is in addition to loss of productivity due to sickness and premature death. Ironically , the tobacco industry, often suggests to governments that they are important players in the economy as they provide tax revenues, but forget to disclose that the bulk of the tax is actually being paid by the tobacco users (i.e. industry are arguably just large tax collectors and no larger a tax payer than many others). Moreover, the fact remains that the tobacco users could have spent the money used to buy tobacco products on other goods in the economy, if they were not tobacco users. Furthermore, except if a government does not care to carry the cost of caring for its population’s health, the cost of treating tobacco-related diseases have been found to outweigh any economic benefits that may be assumed to accrue to any government (3). Also, in addition to the destruction of the environment that results from tobacco farming (2), cigarette butts and other tobacco product waste are said to be the most ubiquitous form of non-biodegradable litter worldwide (4).

The current relatively low smoking rates in the region indeed already translates into significant economic and health burden that the region can ill afford considering the existing burden of the HIV/AIDS epidemic and tuberculosis (5). In addition to increasing the risk for non-communicable diseases such as cancers, chronic respiratory conditions and cardiovascular diseases, tobacco use increases the risk for tuberculosis (TB) (6). In South Africa, similar to the proportion of deaths from cardiovascular diseases attributable to smoking (23%) (7), 24% of all TB deaths are attributable to smoking (8). In other words, about a quarter of deaths from TB can be prevented if smoking was eliminated in this population group. Arguably an achievable target, yet smoking cessation is not routinely practiced in TB treatment centres in South Africa and in the Sub-Saharan Africa region in general.

Evidence-based effective tobacco control policy interventions

In addition to the clinical effectiveness of brief smoking cessation advice (9), several studies have over the years provided evidence for effectiveness of other public policy interventions in reducing tobacco use (3). These policy interventions are now contained in the first global public health treaty – the WHO framework convention on tobacco control (WHO FCTC) (10). The FCTC was negotiated in 2003 and became the first global public health treaty in February 2005. As at September 2010, it had 172 of the 193 member states of WHO as signatories. All signatories, including South Africa, have an obligation to implement the provisions in the FCTC by adopting this as part of their national legislation.

Some key provisions of the FCTC

Measures relating to reducing the demand for tobacco:

• Prevent tobacco industry interference in public policy (Article 5.3)
• Price and tax measures (Article 6)
• Protection from exposure to environmental tobacco smoke (Article 8 )
• Regulation and disclosure of the contents of tobacco products (Articles 9 & 10)
• Packaging and labelling (including the use of graphic warning labels) (Article 11)
• Education, communication, training, and public awareness (Article 12)
• Comprehensive ban and restriction on tobacco advertising, promotion, and sponsorship (Article 13)
• Tobacco dependence and cessation measures (Article 14)

Measures relating to reducing the supply of tobacco:

• Elimination of the illicit trade of tobacco products (Article 19)
• Restriction of sales to and by minors (Article 15)
• Support for economically viable alternatives for growers (Article 17)

Advocacy for translation of evidence to policy/practice

Despite the evidence of effectiveness of these key policy initiatives, many countries in Sub-Saharan Africa who are signatories to the FCTC have not implemented these key provisions. The questions is – what is it that prevents us from moving from scientific evidence i.e. knowledge discovery to policy delivery? This is often related to the gap between policymakers and the researchers that generates knowledge.

South Africa remains a globally recognised leader in enacting comprehensive tobacco control policy and it may be instructive to chronicle key events that lead to enactment of the first tobacco control legislation in South Africa (11) as the lessons learned may indeed be useful (Table 1).

Table 1: Historical overview of key developments leading to tobacco control legislation in South Africa

Tobacco control advocates working closely with health professionals and research institutions played a significant role in institutionalising tobacco control in South Africa. Influencing public thinking and thus public policy can happen in various ways (Fig.1). The economic framing of tobacco control imperative appears to have been a key turning point in South Africa. However, it may be a challenge in other countries to provide evidence-based costing as it is often difficult to collect adequate data to quantify government spending on health especially in instances where external donor spending on health is significant. Nevertheless, the economic frame combined with the health frame appears to be a common turning point for countries that have made recent progress, such as Nigeria and Kenya. This combined with appropriate political mapping to identify potential tobacco control supporters and antagonists upfront, appears to have been the recipe for success in tobacco control advocacy in South Africa and in some other parts of the region that have experienced significant progress.

Figure 1: Framing strategies for tobacco control

Recipe for successful translation from discovery to delivery

• The right context/setting (12) – Anticipate opportunities, gain policy-makers’ trust (continuous dialogue/regular meetings). Involving policymakers from the onset of research initiatives will likely increase their demand for research (evidence pull).
• Partnerships and networks – Brings about diverse skills (public advocacy and government engagement) and membership, but common purpose. Advocates and the media can often serve as knowledge brokers for the researchers and also facilitate dialogue with policymakers and researchers
• Communication: Information exchange should be continuous between scientists and policymakers (through knowledge-brokers) using simple language (e.g. short policy briefs). People interchange: personal contacts helps, or government person becomes researcher or vice versa
• Time and timing – Easier to influence policy if research coincides with governmental interest (evidence pull or demand factor), but this will require flexible donor support.

Conclusions

Tobacco use creates an unhealthy environment and negatively impacts on people’s health. There is need for more research in the areas of economics of tobacco use and policy evaluation. Demand reduction measures, chiefly tax increases, and regulation of public smoking are the most cost-effective ways to reduce consumption and create healthy environments. But, it will require large political capital and scaling up institutional and human capacity to translate research to policy through collaboration between funding agencies, scientists, advocates and policymakers.