01 June 2009

Tobacco's battle for Africa

With its growth slowing in developed countries, the tobacco industry is increasingly pinning its hopes on Africa – but at what cost to public health?

With the increase in cigarette smoking slowing in developed countries, the tobacco industry is increasingly pinning its growth strategy on the developing world, including Africa.

Civil society groups and health organisations have warned that the consequences of increased tobacco use will put even more pressure on Africa's already strained health care systems.

In a presentation delivered at an international summit in Johannesburg last year, "Tobacco: Africa at the crossroads?", Dr Yussuf Saloojee of the National Council against Smoking pointed out that smoking-related disease globally claims 5.2 million lives a year. By 2025 this number is expected to rise to 10 million.

The bulk of the increase in deaths will come from Africa and Asia.

Biggest growth in Africa
"African countries are experiencing the highest increase in the rate of tobacco use amongst developing countries… In the African region tobacco consumption is increasing by 4.3 percent per year," said Cassandra Welch of the American Cancer Society, who also attended the summit.

"This development is driven in part by the tobacco industry, which increasingly targets the developing world as barriers rise and smoking rates fall in more 'mature' markets," she said.

Another aspect of the expected increase in tobacco use has to do with increased spending power. "As the economic situation in Africa improves, more people will smoke in Africa," says Saloojee. He pointed out that in African countries with a higher GDP – like South Africa and Senegal – there was a much higher incidence of smoking than in a poorer country like Ethiopia.

Overall though, smoking rates in Africa are still relatively low, he says. African and coloured South Africans smoke about six to seven cigarettes per day, whites 15 to 20, and Indians in between these rates. Overall, women still smoke substantially less than men do.

Stopping the tide
The rise in tobacco use goes hand-in-hand with the rising prevalence of cancer. As Welch put it, "the single biggest impact on cancer can be made by reducing tobacco use".

According to Saloojee, the thinking used to be that education on the negative effects of smoking would be enough to get people to stop lighting up. But, he points out, we have known since the 50s that smoking causes cancer, and the industry nevertheless continued to grow.

A better alternative is so-called "health promotion", which recognises that education is not enough, and that "we have to change the social and economic conditions under which people live".

If we raise the price of cigarettes, he says, they become less affordable, and people smoke less.

The retort to price increases and regulatory measures is often that they infringe on the "right" to smoke. To this, Saloojee replies that tobacco control is not about changing people's rights, but about changing the balance of choices.

"We've changed the balance of choices. We've made the healthy choice – the decision not to smoke – the easy choice; and we've made the unhealthy choice – the decision to smoke – the difficult choice."

The pen is mightier than the sword
As far back as 1963, the South African Medical Journal identified a number of key anti-smoking measures:

They wrote that: "There should be no hesitation about banning smoking in public places and on public transport... Cigarette advertising should at first be restricted as to quantity and content with a view to its eventual limitation. It might also be advisable to insist that each cigarette packet should carry a notice to the effect that the contents are potentially dangerous to health. The minister of health may also attempt further restrictions of smoking by increasing the taxation on cigarettes."

Still, strong smoking laws, such as those prohibiting tobacco advertisements, were very slow in coming.

A major shift came in 2005, when the United Nation's Framework Convention on Tobacco Control (FCTC) came into force. In essence, this treaty sets out the minimum requirements for tobacco control and asserts it is a human rights issue.

In short, it gives countries the legal weapons with which to fight tobacco use.

The FTCT is not only the world’s first public health treaty, it is also the most rapidly-embraced international treaty, says Patricia Lambert, Director of the International Legal Consortium and of the Campaign for Tobacco-Free Kids.

Today 157 out of a potential 192 countries have agreed to be bound by the treaty and almost 90% of the world's population is protected by it, Lambert says.

Still, even though the FTCT provides a very powerful tool for countries to use in their fight against tobacco, the tobacco industry remains a formidable foe.

What industry is doing
According to Lambert, tobacco is "the only legal product that, when used according to the manufacturers’ instructions, kills or causes disease in more than half of the people who use it".

According to Saloojee, industry puts great effort into framing tobacco control in a negative light and portraying itself as a "co-operative industry being hounded by government". For instance, tobacco companies point out that the industry makes substantial contribution to the country's tax revenues.

The anti-tobacco response to this is that it is not the tobacco companies who are paying those taxes, but the people who are buying cigarettes. If these people were not buying cigarettes, argue the anti-tobacco activists, they would be buying something else.

Industry documents also show a conscious use of social responsibility programmes - such as building orphanages - to improve the image of the industry.

Lambert claims the following are key strategies in British American Tobacco's "Roadmap 2000": "Isolate the anti-smoking movement, target individual activists, win over public opinion, and influence decision-makers". Allegedly to this end, the tobacco industry reportedly funds overseas trips for members of parliament in African countries. According to Lambert, a group of South African MPs went on a luxury trip to the UK and Sweden last year paid for by tobacco money.

Going after the kids
Most alarming though, is the fact that, though illegal, advertising is often aimed at kids or teenagers. This often has to do with the way cigarettes are packaged – in a pink box for young girls, in an iPod-shaped box, or in cheaper boxes containing only a few cigarettes.

According to Welch, the tobacco industry is targeting some of the most vulnerable populations, "going after women and children who are what they describe as a growth market".

Saloojee claims the following is a quote from an industry document, “younger smokers are critical to RJR’s long-term performance. RJR should therefore make a substantial long-term commitment of manpower and money dedicated to younger adult smoker programs.”

(Marcus Low, Health24, updated May 2009)

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