|Year : 2017 | Volume
| Issue : 1 | Page : 8-13
Assessment of tobacco control efforts in three Sub-Saharan African countries
Akindele O Adebiyi1, Akinbode Oluwafemi2
1 Nigeria Tobacco Control Research Group College of Medicine, University of Ibadan, Nigeria
2 Environmental Rights Action/Friends of the Environment, Nigeria
|Date of Web Publication||9-May-2017|
Akindele O Adebiyi
Tobacco Control Research Group, Department of Community Medicine, College of Medicine, University of Ibadan
Source of Support: None, Conflict of Interest: None
Background: Tobacco industry’s undermining of tobacco control goes on unabated in sub-Saharan African countries, especially in Kenya, Nigeria, and Uganda. The Framework Convention on Tobacco Control (FCTC) contains provisions aimed at curbing these activities. However, the level to which FCTC is implemented and the strength of each country’s tobacco control law will determine its usefulness in this regard. We determined the implementation status and strength of tobacco control laws in Kenya, Nigeria, and Uganda. Materials and Methods: The World Health Organization and Campaign for Tobacco-Free Kids websites were queried for secondary data related to tobacco control. Sources and data were disambiguated and reported as tables. Composite scores for implementation were computed based on the number of indicators of the articles of the FCTC reported on by each country. Strength of tobacco control law (SoTCL) was computed based on the total number of domains of the laws meeting a defined acceptable standard. Total obtainable score for implementation and SoTCL were 148 and 38, respectively. Results: On the FCTC, Kenya, Nigeria, and Uganda achieved 75, 61.5, and 46.6% implementation, respectively. SoTCL was weakest in the smoke-free domain for Kenya, tobacco advertisement promotion and sponsorship domain for Nigeria, and packaging and labeling domain for Uganda. SoTCL scores were 18 (47.4%), 20 (52.6%), and 34 (89.5%) for Nigeria, Kenya, and Uganda, respectively. Conclusion: Kenya, Nigeria, and Uganda will need to strengthen their tobacco control laws through appropriate amendment as well as regulatory mechanisms that guarantee alignment with FCTC and the implementation thereof.
Keywords: FCTC implementation, tobacco control, tobacco industry
|How to cite this article:|
Adebiyi AO, Oluwafemi A. Assessment of tobacco control efforts in three Sub-Saharan African countries. Niger Postgrad Med J 2017;24:8-13
|How to cite this URL:|
Adebiyi AO, Oluwafemi A. Assessment of tobacco control efforts in three Sub-Saharan African countries. Niger Postgrad Med J [serial online] 2017 [cited 2017 Jun 23];24:8-13. Available from: http://www.npmj.org/text.asp?2017/24/1/8/205974
| Introduction|| |
Tobacco-related deaths are projected to become the leading single cause of death by 2020, causing more than 10% of deaths. It is also predicted that half of all the lifetime smokers will die prematurely as a result of tobacco use, losing 20–25 years in life expectancy compared with nonsmokers. Despite this prediction, people still continue to use tobacco products in low- and middle-income countries. A global market review (2005–2014) revealed that cigarette sales continue to decrease in all regions except Asia Pacific and Middle East and Africa regions (8 to 5% in North America, 12 to 9% in Western Europe, 5 to 4% in Latin America, 14 to 10% in Eastern Europe, 54 to 65% in Asia Pacific, and persistently 7% in Middle East and Africa). This has been attributed to the deliberate resolve of transnational tobacco companies to shift attention to low- and middle-income countries, especially in Africa. A recent document from Phillip Morris International (PMI) highlighted the opportunities to develop untapped markets, wherein their shares of cigarette sales are low. This has been demonstrated in Nigeria, wherein PMI imported 122 million units of cigarettes into the country and attempted to import additional 550 million units into the country before the anti-tobacco advocates raised an alarm. In other parts of Africa, these activities also go on unchecked such as the secret meeting of some Ugandan policy makers with officials of British American Tobacco Company and the uncovering of evidence of bribery involving British American Tobacco Company in East Africa.,
The World Health Organization’s Framework Convention on Tobacco Control (WHO FCTC) was a direct response to the globalization of the tobacco epidemic and the “tobacco industry” meddlesomeness in the efforts aimed at curbing this epidemic. It is the first treaty negotiated under the auspices of the WHO and represents a paradigm shift by emphasizing the importance of demand reduction strategies as well as supply issues. Since entering into force on 27 February 2005, up to 180 parties (countries that are bound under international law by the provisions of the FCTC) signed on to it as on March 2015, and a steady progress propelled by tobacco control advocates had been made in reversing the gains of the “tobacco industry” as well as holding governments accountable for regulating the industry within the ambit of the public health agenda.,,
To provide a rationale for evidence-based decision-making, article 21.1 of the FCTC states that “each Party shall submit to the Conference of the Parties, through the Secretariat, periodic reports on its implementation of this Convention.” This requirement was further concretized with an establishment of reporting arrangements by the Conference of the Parties (COP) at its first session in 2006. In recent years, Kenya, Uganda, and Nigeria have intensified their action leading to the passage of national tobacco control laws in a bid to domesticate the FCTC. Though tremendous progress has been made in sub-Saharan African countries regarding tobacco control, the gaps in the implementation status as well as the tobacco control laws may reverse these gains if they are not made visible for a likely comprehensive and urgent intervention. In this study, we present evidence of these tobacco control gaps in Kenya, Uganda, and Nigeria.
| Materials and Methods|| |
We analyzed the WHO, World Health Organization Afro region and Campaign for Tobacco-Free Kids websites for secondary data related to tobacco control.,, We disambiguated secondary data and presented the analysis done in tables. The status of implementation scores was computed by summing the number of indicators for each article of the FCTC that is reported to the WHO by each country.
The FCTC lays out a broad framework of obligations and rights and requires the parties to implement effective tobacco control measures covering a range of topics which are contained in 38 articles. Our analysis included the following sections and articles: Part III, which contains the core demand reduction provisions, is made up of articles 6–14; Part IV (core supply reduction provisions) is made up of articles 15–17; Parts V and VI (articles 18 and 19), which refer to issues related to the protection of the environment and liability, and Part VII containing articles 20–22, which is related to scientific and technical cooperation as well as communication of information. We left out the Parts I and II containing articles 1–4, because they contained only introduction, objective, guiding principles, and general provisions for the whole of the document. Similarly, we did not include Part VII (articles 23–26), Part IX (article 27), Part X (articles 28 and 29), and Part XI (articles 30–38), because they only spell out institutional arrangements such as conference of parties, secretariat, settlement of disputes, development of the convention, and final provisions.
For each article, the number of indicators reportable represents the maximum number that can be obtained for that article. Thus, we calculated the implementation score as the summation of scores across the total number of articles and reported this as a percentage of the total maximum obtainable score of 148. The strength of tobacco control was computed using a composite score of all the domains examined (total obtainable score of 38). A total of three domains containing 19 subdomains were examined and scored. For each subdomain, an unambiguous definition of the terms in tobacco control act, which aligns with the recommendations of the FCTC, was scored 2, whereas an unclear definition or nonalignment with the provisions of the FCTC was scored 0. Each country’s score was then converted to a percentage of the maximum score obtainable. We regarded a less than 50% score as poor, 50–69 as fair, and ≥70% as excellent.
| Results|| |
[Table 1] shows the status of implementation of the articles of the FCTC at the country level. This reveals that all the three countries performed well regarding the implementation of articles 9, 10, and 11, whereas they all performed poorly with regard to the article 17. Kenya performed excellently except for the articles 14 and 17. Nigeria performed poorly with regard to the articles 12, 17, 19, and 22. Uganda performed very poorly on the articles 7, 13, 14, 17, and 18. Apart from the articles on which all countries performed excellently, Nigeria performed excellently with implementation of the articles 15 and 16, whereas Uganda performed excellently on the article 12.
|Table 1: Status of implementation of Framework Convention on Tobacco Control|
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Kenya achieved 75% implementation of the FCTC, Nigeria achieved 61.5% implementation, and Uganda achieved 46.6% implementation.
[Table 2] reveals the strength of the tobacco control law currently in each country. The strength was poorest for the Smoke-Free domain for Kenya (4/16), Tobacco Advertisement Promotion and Sponsorship domain for Nigeria (6/18), and for the Packaging and labeling domain for Uganda (0/4).
Overall, the strength of the tobacco control law on a scale of 0–100 was 47.4% for Nigeria, 52.6% for Kenya, and 89.5% for Uganda.
| Discussion|| |
The level of implementation of the FCTC is dependent on the extent to which a comprehensive national action plan is available. We have shown that the level of implementation was greatest for Kenya, which was not surprising as the country had in place a national tobacco control action plan, which actually facilitates implementation of key recommendations of the Tobacco Control Act 2010–2015. This is in keeping with Article 5.1 of the WHO FCTC, which requires countries to develop, implement, update, and review comprehensive multisectoral national tobacco control strategies, plans, and programs. The poor performance of Nigeria on the article 12, which deals with education, communication, training, and public awareness, may be a reflection of the lack of adequate planning and funding resulting from a failure of leadership on the part of the National Coordinating Office in the Federal Ministry of Health. Hitherto, tobacco control efforts had been driven solely by Civil Society Organizations, whereas one of the key roles of the government in the tobacco control arena is to create awareness. Such activities included the concerted efforts by three major Nigerian NGOs − Environmental Rights Action/Friends of the Earth (ERA/FoEN), Nigerian Tobacco Control Alliance and the Coalition toward the passage of the aborted Tobacco Control Bill of 2009, and the joint Lagos State Government and ERA/FoEN efforts at suing five tobacco companies to recoup the money spent in treating people, who suffer from tobacco-related illnesses. A study in Lagos among the pharmacists showed that only 51.9% of the respondents ever heard of the FCTC, while a little over half (53.8%) were aware of any law in Nigeria controlling tobacco use. For Uganda, the FCTC articles that were least implemented include the article 13 on Tobacco Advertising, Promotion, and Sponsorship, and the article 16 regarding sales to and by minors. The degree of implementation of these two articles always reflects the extent to which the tobacco industry is able to peddle an influence within the government circles.
In recent years, all the tobacco industries intensified their efforts to undermine the Ugandan tobacco control laws, and this included secret meetings between British American Tobacco (BAT) officials and members of the Ugandan parliament. This clearly shows a conflict of interest and a failure to protect tobacco control from industry influence. It is likely that the poor implementation status of the FCTC articles informed the redoubling of efforts invested in the drafting of the tobacco control regulations in Uganda. Of the three countries, the tobacco control laws of Uganda appear to be the strongest, because it meets most of the FCTC standards. However, the exact specifications for the placement of the warning messages, its size, as well as the exact position on the prohibition of misleading information still remain unclear in Uganda. In this area, the Uganda law failed to meet the standards of the FCTC. The specification regarding packaging and labeling is very important, because it is one of the cardinal ways of warning people about the dangers of tobacco, and the WHO recommends this as one of the key measures for reducing the demand for tobacco. Smoking restriction as opposed to 100% smoke free policy in all indoor, public transport and restaurants are typical features in tobacco industry narratives. The failure of the Nigerian and Kenyan laws to prescribe 100% smoke-free places is highly regrettable and only mirrors the success of the tobacco industry lobbyists in getting across to parliamentarians. There is incontrovertible evidence that there is no safe level of tobacco smoke. It is based on this that the COP to the WHO FCTC concluded that the only proven way to adequately safeguard the health of people from the deleterious effects of second-hand tobacco smoke is to ensure 100% smoke-free environments. The provision of Designated Smoking Areas (DSAs) to cater for the restrictions specified in the laws goes contrary to the requirements of the FCTC. In fact, scientific studies and credible organizations have proved and asserted that DSAs and expensive room ventilation systems do not protect from the dangers of second-hand smoke exposure.,,,
The failure of the Nigerian law to completely ban tobacco advertising, promotion, and sponsorship at the point of sale, in domestic print media, and other media such as pamphlets and flyers is also a big minus for the Nigerian Tobacco Control Act. Inserting a clause specifying that consenting adults can have advertisement and promotion extended to them is a clever narrative used by the tobacco industry but as observed in an article by Chapman, using “persuasive” advertising as often present in un-solicited communication between tobacco industry and the unsuspecting public affects consumers autonomy because it convinces them to purchase what they do not need. Inclusion of this special clause in the Nigerian National Tobacco Control Act belies the extent to which the tobacco industry penetrated government circles. During the process of the passage of the law, it could be recalled that a Director of Public Prosecution from Oyo State Ministry of Justice actually openly opposed the provisions of the National Tobacco Control Act on the floor of the National Assembly. More recently, a Nigerian delegate to the COP of the WHO FCTC in India stood before delegates from other countries to query the evidence behind the addictiveness of tobacco. These are obvious signs of Tobacco Industry Interference, which calls for vigilance on the part of the coordinating government unit as well as the other tobacco control stakeholders. More recently, PMI at their “2016 Investors Day” unmasked strategies aimed at aggressively developing untapped markets such as Nigeria, Kenya, and Uganda.
Therefore, the weaknesses that we have highlighted in our analysis make it imperative that anti-tobacco stakeholders need to work relentlessly to strengthen their existing tobacco control laws through the instruments of regulations and amendments.
On the basis of the modeled trend of tobacco and cigarette use by the WHO, Uganda will have the most reduction in tobacco and cigarette use prevalence by 2025 in comparison with the 2010 prevalence (4.0 and 3.0% reduction in prevalence, respectively) followed by Kenya (2.4 and 1.8% reduction in prevalence, respectively). Unfortunately, on the basis of the current trend, Nigeria is the only country out of the three countries analyzed that may experience an increase in tobacco and cigarette use prevalence by 2025 (4.2 and 2.9% increase in prevalence, respectively). This reinforces the validity of our result, because the relative strength of the tobacco control laws correlates with the probability of a reduction/increase in use predicted by the WHO for the three countries under reference. The implication of this finding is that countries that desire to achieve the smoking component of the global Non-Communicable Disease (NCD) target of reducing tobacco smoking by 30% by 2025 would have to pay attention to the strength of their tobacco laws as well as its implementation. According to the WHO, Nigeria, with a relatively weaker tobacco control law, will experience an increase in tobacco smoking, which will far outweigh the increase in cigarette smoking. This will partly be fueled by the deliberate plan of the tobacco industry to infiltrate the market with the so-called “reduced risk products” such as heated tobacco products and nicotine-containing products. Already a water-based tobacco-smoking practice known as “Shisha” is trending in Nigeria with bars and restaurants openly advertising it and popular online sales outlets offering them for sale. The availability of this product in many flavors (including menthol), which makes it less irritant to the throat, often serves as a means of initiating and sustaining tobacco smoking. Conversely, the WHO recommends the banning of menthol − including its analogs, precursors, and derivatives from cigarettes because of its negative effect in sustaining the habit of smoking.
The implementation status data were based on self-report from national governments. Therefore, the main limitation of our study is that some of these self-reports may have been amplified beyond what is available in each country. Nonetheless, our study provides a template for a review of country-level tobacco control efforts.
| Conclusion and Recommendations|| |
The status of the implementation of tobacco control in the three countries under reference gives us an idea of the great work that remains to be done in achieving the smoking component of the global NCD target. All the three countries will need to strengthen their tobacco control laws through the mechanisms of enactment of implementation regulations and amendments. Furthermore, a broad-based coalition will be needed to rapidly build a strong platform for the engagement of policy makers. A key function of this coalition will be the monitoring of the tobacco industry and their allies to ensure that tobacco control is insulated from their negative influence. It must be reiterated that an ownership of the entire tobacco control process belongs to national governments; therefore, building capacity to respond promptly with evidence of best practices will be a key area that academia have to partner with other stakeholders on. In addition, Civil Society Organizations will need to keep their respective governments accountable for their action.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006;3:e442.
Fagerström K. The epidemiology of smoking. Health consequences and benefits of cessation. Drugs 2002;62(Suppl 2):1–9.
WHO Framework Convention on Tobacco Control. WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland; 2005. ISBN 978 92 4 1591010.
Action on Smoking and Health. BAT’s Africa Footprints. ASH; 2008. p. 1-23. ISBN 1 872428 74 6.
Agaku IA, Akinbode OA. Tobacco control in Nigeria − policy recommendations. Tob Induc Dis 2012;10:8.
World Health Organization. The WHO Framework Convention on Tobacco Control: 10 Years of Implementation in the African Region. WHO Regional Office for Africa; 2015. ISBN: 978 9290232773.
Drope J. Nigeria tobacco situational analysis coalition. In: Drope JM, editor. Tobacco Control in Africa: People, Politics, and Policies. UK and USA: Anthem Press; 2011.
Poluyi EO, Odukoya OO, Aina BA, Faseru B. Tobacco-related knowledge and support for smoke-free policies among community pharmacists in Lagos state. Niger Pharm Pract 2015;13:486.
World Health Organization. Conference of the Parties to the WHO Framework Convention on Tobacco Control. Second Session. First Report of Committee A. Geneva: World Health Organization; 2007. Available from: http://apps.who.int/gb/fctc/E/E_it2.htm
. [Last accessed on 2016 Apr 12].
Sebrie E, Glantz S. “Accommodating” smoke-free policies: tobacco industry’s Courtesy of Choice programme in Latin America. Tob Control 2007;16:e6.
Potera C. Smoking and secondhand smoke: Study finds no level of SHS exposure free of effects. Environ Health Perspect 2010;118:A474.
U.S. Department of Health and Human Services (HHS). The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. HHS, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2006. Available from: http://www.surgeongeneral.gov/library/secondhandsmoke/
. [Last accessed on 2016 Oct 12].
Wagner J, Sullivan DP, Faulkner D, Fisk WJ, Alevantis LE, Dod RL et al.
Environmental tobacco smoke leakage from smoking rooms. J Occup Environ Hyg 2004;1:110-8.
Pion M, Givel MS. Airport smoking rooms don’t work. Tob Control 2004;13(Suppl 1):i37–40.
American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE). ASHRAE Position Document on Environmental Tobacco Smoke. Approved by ASHRAE Board of Directors; October 22, 2010. Reaffirmed by ASHRAE Technology Council; June 25, 2013. Available from: https://www.ashrae.org/about-ashrae/position-documents
. [Last accessed on 2016 Aug 16].
Chapman S. The ethics of tobacco advertising and advertising bans. Br Med Bull 1996;52:121-31.
World Health Organization. Global Report on Trends in Prevalence of Tobacco Smoking. World Health Organization; 2015. ISBN 978 92 4 156492.
World Health Organization. Advisory Note: Banning Menthol in Tobacco Products. Geneva: WHO Study Group on Tobacco Product Regulation (TobReg); 2016.
[Table 1], [Table 2]