IntroductionTobacco it is crucial that African countries urgently

IntroductionTobacco use has imposed a huge and growing public health burden worldwide with thethreat to global health greater today than ever before 1. Even in Africa, with onlyrecent increases in smoking prevalence, lung cancer is now the most common cause ofcancer attributable mortality in men 2. This underscores the rapidity of smokinguptake in Africa that has led to tobacco-related conditions emerging as an increasinglyimportant public health problem on the continent 3.Although Africa had the lowest smoking prevalence compared with other world regions(12%) 4, it has increased by 57% between 1990 and 2009 5. This contrasts withWestern Europe, the area with the highest smoking prevalence, which witnessed abouta 26% decrease in tobacco use during the same period 5. Of further concern, is thesmoking prevalence in African youth because, unlike in adults, it was not significantlylower than all the other World Health Organization (WHO) regions, and is a reflectionof the tobacco industry’s success in promoting tobacco uptake in the region 6.Tobacco related morbidity and mortality in Africa will not only have a devastatingimpact on health but also on development and economic growth on the continent.Therefore, it is crucial that African countries urgently target tobacco use and implementmeasures to curb the uptake and halt the use of tobacco products. This paper aims todiscuss the current tobacco control strategies in Africa, highlight the difficultiesassociated with the implementation of such initiatives and deliberate on the wayforward.Tobacco control strategies: WHO Framework Convention on Tobacco Control(WHO FCTC)The WHO FCTC, adopted by the World Health Assembly in May 2003, requires stateParties to adopt and implement tobacco control measures, and guides governments withsuggested policies and programmes for reducing tobacco use 7. Among the keystrategies advocated are banning tobacco advertising, promotion and sponsorship,introducing smoke-free policies by prohibiting smoking in public and work places,imposing high taxes on tobacco products, introducing health warnings on cigarettepackages, implementing anti-tobacco media campaigns and promoting smokingcessation. These approaches are all effective, involve minimal costs and should be easyto execute 8. Nevertheless, numerous obstacles exist globally, and particularly inAfrica and other developing regions that makes what should be a simple endeavour,rather difficult to achieve.Tobacco control strategies in AfricaIn the recent past, there have been significant advances in the battle against tobacco inAfrica, with achievements including ratification of the WHO FCTC and the passing oftobacco control legislations in several countries. In the WHO African Region, themajority (43) of the 47 countries have ratified the WHO FCTC 9.However, the implementation of the WHO FCTC in Africa has been variable, asillustrated by Husain and colleagues 10. They described the status of tobacco controland prevention efforts in 23 African countries and reported that implementation ratesof the WHO FCTC ranged from 9% in Sierra Leone to 78% in Kenya 10. Notably,the overall implementation rate in the WHO Africa region, at 43%, was lower than the53% found in the remaining five WHO regions, which comprised data from 10712345678910111213141516171819202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364654countries 10. This highlights that although the majority of African countries haveratified the treaty, they have not optimally fulfilled their obligations under the WHOFCTC provisions 10 and that they lag behind other world regions. Bilano andcolleagues, who analysed global trends in tobacco use, concur. Of the 178 countriesfor which projections were made in their analysis, African countries together with thosein the Eastern Mediterranean Region had among the worst outlook for achievingtobacco control targets by 2025 11.The modest progress in WHO FCTC implementation in Africa include many countrieshaving legislation or policies covering some aspects of the treaty. However, only a fewcountries meet the standards of the individual WHO FCTC articles with regards tocomprehensive implementation; no African country complies with the best practiceguidelines across all key areas. The focus of tobacco control strategies in Africa includeraising tobacco taxes, protection from exposure to tobacco smoke with smokingrestriction in certain venues, the packaging and labelling of tobacco products with theintroduction of warning messages on cigarette packaging, and restricting or banningtobacco advertising, promotion and sponsorship 12.The lack of compliance with the best practice guidelines for tobacco control strategiesis likely to lead to their ineffective or sub-optimal implementation. For example, inKenya, smoke-free laws comply only partially with WHO FCTC recommendations;consequently, measures are ineffective to protect non-smokers from tobacco smokeexposure in bars and restaurants 13. Braithwaite and colleagues have questioned theeffectiveness of current taxation policies in curbing tobacco use in African countries.This was because although taxation policies of any kind to reduce tobacco consumptionwere present in eight of the nine African countries they surveyed in 2014, taxes ontobacco products were below 70% in most of the countries except for Ghana (88%) andSenegal (70.9%) 14. According to a WHO analysis, Madagascar and Seychelles werethe only nations in Africa in 2014 with a sufficiently high tax of greater than 75% ofthe retail price of cigarettes 15.That tobacco taxes are one of the most effective ways to reduce or stop tobacco useamong current users or to prevent the uptake among non-smokers has been shown inSouth Africa where total taxes on cigarettes increased from 32% to 52% of the retailprice between 1993 and 2009 15. This led to a sizable reduction in tobacco use; a 10%increase in the real price of cigarettes led to a 6-8% decrease in consumption 16. Also,government tobacco tax revenues increased nine-fold 15. In contrast, Sierra Leone,which has no policy on taxation, an absence of comprehensive bans on tobaccoadvertising, promotion and sponsorship 14 and a low WHO WCTC implementationrate (9%) 10, had the highest prevalence of smoking among men in Sub-SaharanAfrica (33.3%) 4.Of the countries examined, Braithwaite and colleagues found that cigarette pricesincreased only in Congo and Nigeria, but declined in Senegal and South Africa, whileremaining the same in four other African countries (Ghana, Kenya, Togo and Uganda)for about two years 14. Cigarettes may become more affordable if their price drops orremains steady while simultaneous economic growth results in greater disposableincomes. Confirming this supposition was the WHO, which reported that South Africaand Botswana were among the countries where incomes and purchasing power hadgrown rapidly to the extent that tobacco had become increasingly affordable 15. Thisled to an escalation in consumption, despite rises in tobacco taxes, because the resultantprice increases were not large enough to counter growth in real incomes. Therefore, it12345678910111213141516171819202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364655is not only important to introduce tobacco excise taxes but to ensure that they aresufficiently high to be optimally effective.The tobacco industry in AfricaA major obstacle that African countries face in their efforts to implement tobaccocontrol policies is strong obstruction from the tobacco industry, which is vocal andrelentless in its opposition to effective policies 17. Tactics employed include lobbyingpolicymakers to prevent future policies by presenting misleading economic arguments,rebranding political activities as corporate social responsibility, drafting weak laws andusing litigation to weaken, postpone or prevent strong tobacco control legislation 12,18.For example, the tobacco industry succeeded in preventing advertising bans in SierraLeone and Uganda 18. In Kenya, their challenge of the Tobacco Control Act led tothe suspension of the public smoking ban and their lobbying of policymakers resultedin weak tobacco control legislation 12. In Mauritius, the industry used delay tactics toundermine the law for implementing graphic health warnings on packaging 12.Tobacco industry interference delayed the ratification of the WHO FCTC in Namibia;this is a key step in tobacco control, which provides support to governments and enablesthe strengthening of tobacco control legislation 19. When this eventually failed,British American Tobacco (BAT) used intimidation tactics and threatened to take theNamibian government to court if the Tobacco Products Control Act was implemented.BAT cited violations of their ‘Rights to Property’ and ‘Rights to Freedom ofExpression’ as provided by the Namibian constitution 19. The tobacco conglomeratesincreasingly use litigation to intimidate African nations from implementing effectivepolicies 18. However, in Uganda, BAT unsuccessfully appealed against the ban onpublic smoking, and in South Africa, the tobacco industry went to court on the groundsthat the ban on tobacco advertising and promotion was unconstitutional, but theirapplication was dismissed 12.The tobacco industry further encourages ineffectual tobacco control policies in Africasuch as promoting voluntary regulation of smoke-free zones to avert strict regulationthrough legislation 12. Consequently, the tobacco industry’s unremitting efforts onmultiple fronts to undermine tobacco control measures has led to slow and unevenimplementation of the WHO FCTC 18. These tactics highlight that tobacco industryinterference with governments’ tobacco control initiatives remains one of the greatestchallenges to curbing this epidemic in Africa.Tobacco companies falsely convince African governments that tobacco productionleads to economic development 20. They have agricultural lobbies such as theInternational Tobacco Growers’ Association (ITGA), which promote tobacco farmingas a lucrative income source. However, in depth scrutiny reveals negativeenvironmental impacts, exploitive contracting practices and negative health effects 20that in fact present an economic threat. For example, tobacco farmers themselves,including their children who work in the fields, may absorb nicotine, with the amountas high as that found in 50 cigarettes 21. This leads to nicotine poisoning known asgreen tobacco sickness; children are particularly vulnerable because of their smallersize compared to the amount of nicotine absorbed. In Malawi, approximately 80 000children work in tobacco farming which has a devastating impact both on their healthand their ability to receive adequate schooling 21. The cycle of poverty is then12345678910111213141516171819202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364656perpetuated and it is not surprising that African countries dependent on tobacco farmingare among the world’s poorest nations 20.While legislation restricts tobacco promotion activities in high-income countries 2, inAfrica, unfortunately, tobacco companies are able to use aggressive marketing tacticsto promote smoking in previously underexploited markets. They successfully targetpotential growth markets such as women and the youth who are vulnerable groups withtraditionally low tobacco use 18. The tobacco industry exploits the economic growth,changing social norms and population demographics in Africa to maximally expand itsconsumer base 14. The pivotal role that it plays in escalating the worldwide use oftobacco has, unsurprisingly, led to it being appropriately labelled the vector of thetobacco epidemic 18.Civil society and tobacco control in AfricaCivil society has a major role to play in holding governments accountable forresponsible stewardship, and their influence and importance should not beunderestimated. Advocacy efforts aim to de-normalising smoking, increase awarenessof the harmful effects of tobacco use and overall promote the anti-tobacco agenda.In Uganda, for example, which did not have comprehensive national tobacco controllegislation, smoke-free legislation was introduced as a result of public interest litigation12. This was possible because of the country’s favourable legal system, which allowsan individual or organisation to bring an action against the violation of anotherindividual’s or group’s human rights. Unfortunately, these smoke-free regulations werepoorly enforced and underlined the need for continued public awareness campaigns togain public support and become self-enforcing 12. Nevertheless, great advances havebeen made in Uganda following the efforts of several stakeholders including theMinistry of Health and civil society organisations, despite strong resistance from thetobacco industry 22, 23. The Ugandan Parliament introduced the Tobacco ControlAct 2015, which is in keeping with the strongest tobacco control policies globally, andpositions the country as a leading example for tobacco control in the region.Another example of the importance of the role played by civil society is in Niger wheretobacco control legislation allows tobacco control organisations to initiate actionagainst violators of the law. A non-governmental tobacco control organisationsuccessfully sued two tobacco companies for violating the advertising ban 12.Additionally, the media may exert pressure on governments to promote tobacco controllegislation, and in resource-constrained African nations, serve as government’watchdogs’ 19. For example, the Cancer Association of Namibia engaged with themedia to follow-up with government on the pending tobacco control legislation. Thispressure from news media who frequently highlighted the issue may have contributedto the introduction of Namibia’s Tobacco Products Control Act in 2010.Civil society organisations also serve as gatekeepers and collaborating platforms. Forexample, Vision for Alternative Livelihood Development in Ghana increases awarenessof the harmful effects of tobacco use among the public 20. They also build capacityto ensure effective implementation and enforcement of national tobacco controlpolicies.Bloomberg Philanthropies, the Bill and Melinda Gates Foundation, and the CanadianInternational Development Research Centre are the three largest internationaldevelopment partners to offer financial and technical support for tobacco prevention12345678910111213141516171819202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364657and control in Africa 20. Among other initiatives, they assist developing countries inimplementing effective tobacco control policies, with a specific goal to prevent atobacco epidemic from “taking root” in Africa.The way forward for AfricaDespite the huge obstacles that African nations face in their quest to introducecomprehensive tobacco control policies, many countries have achieved measuredsuccess while others such as such as Uganda, South Africa and Mauritius haveaccomplished significantly more in their efforts to curb tobacco use. Nevertheless,Africa still needs to urgently intensify efforts to implement effective tobacco controlpolicies which are fully compliant with the WHO FCTC 10, 12. Otherwise, the currenttobacco trends will continue with potential devastating consequences. The overallsmoking prevalence in Africa will increase by more than a third (37.5%) over twodecades; i.e. from 16% in 2010 to 22% in 2030, and the number of smokers will tripleby the end of this century 2. The American Cancer Society reported that by 2100″without action, Africa will grow from being the fly on the wall, to the elephant in theroom” 6.The powerful tobacco industry is irrefutably the driving force behind the global tobaccopandemic with its vast resources and predatory practices, and the major barrier to WHOFCTC implementation in Africa 12. Therefore, in the battle against rising rates oftobacco use on the continent, a prerequisite is to actively address tobacco industryinterference by monitoring its activities, exposing its misconducts and thereby changingattitudes to the industry 18. It is no coincidence that countries with the most successfultobacco control policies across all income categories are those who most rigorouslymonitor industry activities.The tobacco industry frequently encourages certain government ministries’ oppositionto the introduction of comprehensive tobacco control legislation. These may includethe agricultural, and trade and industry departments, among others, which may havecompeting priorities to that of the health ministry, and consequently influence thedrafting of ineffective tobacco control legislation. A whole-of-government approach isrequired with tobacco control integrated in all government programmes including thetaxation and commerce sectors 24 .Considering that the tobacco industry generally exerts more power and influence atnational than sub-national levels, it may be prudent and perhaps more feasible tointroduce tobacco legislation at sub-national levels 12. Although this may not offerprotection to the entire population, enacting and enforcing tobacco legislation at local,state, provincial or municipal levels may be easier and more effective. Whether theenforcement of current sub-national legislation in Africa is effective has yet to bedetermined 12.Technical support and capacity building is needed in Africa to enable countries tocompetently handle legal challenges to tobacco control and to deal with the industry’ssubversive tactics 18. Further, African nations need to prioritise resources to buildcapacity for drafting comprehensive WHO FCTC compliant legislation 12. Asdemonstrated in Namibia, key obstacles to the introduction of tobacco controllegislation, together with competing priorities and administrative delays, wereinsufficient staff and legal capacity 19. The lack of legal expertise within the Ministryto challenge the false information provided by BAT to the Namibian Health Ministrythat it could not ratify the WHO FCTC prior to passing a national tobacco control12345678910111213141516171819202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364658legislation likely also delayed its ratification. Consequently, it took nearly 20 years forthe country to pass the Tobacco Products Control Act.Resources are also needed to generate locally relevant research on tobacco use 12, 25.Importantly, economic studies should be undertaken to conclusively refute the negativeimpact of tobacco control policies in Africa. Tobacco is grown in over 125 countriesglobally, including in Africa, and the role it plays in employment, tax-revenuegeneration and trade balances in some countries is highly promoted by the tobaccoindustry 26. However, independent studies have demonstrated that there will be aminimal negative impact on economic growth, employment, tax revenues and foreigntrade balances over the medium and long term in most countries even with very strongtobacco-control policies.Tobacco control should be integrated in the implementation of the SustainableDevelopment Goals. There is a need to switch from tobacco farming to other crops,which has been successfully achieved in a programme in Brazil with a switch to fruitor vegetable cultivation 21. A government programme that encourages the use oflocally-grown fruit and vegetables for school lunches ensures a market for theirproduce. In this way a country’s economic dependence on tobacco farming as well astobacco’s negative health consequences are reduced, and the cycle of poverty is broken.Relevant research from Africa will inform policies and may increase political will bygenerating vital political attention for tobacco control. Moreover, tobacco controlmeasures based on locally garnered evidence are likely to be more effective with suchresearch also potentially refuting tobacco industry myths. High quality research in allSub-Saharan African countries, of which there is currently a dearth, should also includedata on smoking incidence, prevalence, trends and uptake facilitating factors, andevidence of the implementation and effectiveness of tobacco control policies 14. Suchdata will demonstrate the degree of success of strategies implemented in relation totobacco use patterns and underscore shortcomings in existing policies. Civil society,NGOs and researchers in the field need to educate and pressurise African politiciansand governments to implement and enforce effective tobacco control policies.Expecting African countries to implement comprehensive and effective tobacco controlpolicies with efficient monitoring and enforcement of such activities is not unrealistic.Some countries on the continent have already shown that they not only have the abilityto implement effective tobacco control strategies but that they are also able to be at theforefront of global tobacco control initiatives. Two African nations, South Africa andMauritius, together with Bahrain are the world’s first three countries to ban smoking invehicles carrying children 2. Additionally, while Mauritius is the only country on thecontinent with graphic health warning labels on packaging, their warnings are the thirdlargest in the world, covering 60% of the front and 70% of the back package displayareas 12. This highlights that with sufficient political will African nations have thepotential to meet their commitment to the WHO FCTC and prevent a full-scaleescalation of the tobacco epidemic 18.ConclusionsThe lower rates of tobacco taxation, weaker smoke-free policies and fewer restrictionson tobacco advertising in Africa compared with high-income countries is a key factordriving the tobacco epidemic on the continent 14. These shortcomings, enabled by thetobacco industry thwarting anti-tobacco initiatives, have allowed it to expand itsmarkets in the region by capitalising on economic growth, changing social norms and12345678910111213141516171819202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364659population demographics. Consequently, while there has been progress, the currentcommitment of most African countries to the WHO FCTC has not translated intoeffective delivery of meeting the WHO Global Non-communicable Disease (NCD)Action Plan goal of a 30% relative reduction in tobacco use by 2025 compared with2010 8. This is of great concern because tobacco use is not only a threat to health butalso to sustainable human development.The rapid expansion of tobacco use in Africa needs to be counteracted with strongtobacco control policies, which is one of the most effective population-based strategiesfor NCD prevention. African countries need to intensify efforts to implement effectivetobacco control policies that are fully compliant with the WHO FCTC 12. Theseshould include higher tobacco excise taxes, stronger smoke-free policies, bans ontobacco advertising, promotion and sponsorship, graphic warnings on cigarettepackages and anti-smoking mass media campaigns 25. Otherwise, the recent increasesin economic development and population growth will spur the widespread uptake oftobacco use and lead to loss of hundreds of millions of lives in this century due to