Introduction
By global comparisons, smoking prevalence is relatively low across the continent of Africa. Yet by 2025, the World Health Organization (WHO) projects the total number of tobacco users in Africa will increase to 62m, of whom 51m will be smoking combustible tobacco.[i] The opportunities to reduce the burden of non-communicable disease, suffering and premature deaths presented by tobacco harm reduction (THR) are therefore huge. Appropriate, accessible and affordable safer nicotine products (SNP), supported by product regulation, could help create a smoke-free Africa and, unlike most tobacco control interventions, this can be achieved at minimal cost to governments. This makes THR particularly well suited to resource-stretched low and middle-income countries (LMIC), such as those in Sub-Saharan Africa which are the focus of this Briefing Paper.
Economic context
Sub-Saharan Africa comprises 48 countries that are home to about 1.14b people. It is geographically and economically diverse and boasts some of the world’s richest natural resources. The Gross Domestic Product (GDP) of the region was estimated at US$1.705 trillion in 2020,[ii]with Nigeria and South Africa being the largest economies. The three poorest countries in the world are also located here: Burundi (GDP per capita US$239), Somalia (US$438) and Mozambique (US$448).[iii]
The economic role of tobacco
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% of Africa’s output), Zambia (16.4%), Tanzania (14.4%), Malawi (13.3%) and Mozambique (12.9%).[iv] In 2018, Africa produced 722,187 tonnes of tobacco leaf, representing 11.4% of total global production, with Sub-Saharan Africa being the principal source (around 90%).
Tobacco is an important source of revenue: for example, in 2018, Malawi exported tobacco leaf worth US$529 million, representing 8.5% of the country’s GDP that year. Various initiatives are underway to encourage transitions away from tobacco growing to other agricultural products.
Tobacco in Africa
There is a long history of tobacco use in the region dating back to its introduction by the Turks, Portuguese and French in the 16th and 17th centuries. A wide range of tobacco products are used including manufactured cigarettes, chewable tobacco, snuffs for nasal inhalation, and hand-rolled cigarettes which are often produced domestically by small local manufacturers. Some of the small local cigarette manufacturers include Smoky Treats in South Africa, Eastern Company in Egypt, Afra Tobacco and Cigarette Company in Sudan and Nyasa Manufacturing Limited in Malawi. Larger cigarette manufacturers active in the region include Gold Leaf Tobacco, British America Tobacco, Phillip Morris International and JTI.
Tobacco leaf is also deeply anchored in some societies where it is offered as a gift during traditional ceremonies like weddings. In addition, it can be used for medicinal purposes for example dressing wounds and as an anaesthetic for toothache.[v]
Smoking
Overall smoking rates in Africa are low by international comparisons, with a prevalence of 8.4% across the continent. However, the region is one of only two globally in which the WHO projects an increase in the absolute number of smokers, due to population increases.[vi]
The estimated number of people who die each year due to tobacco smoking in the region is 205,857, accounting for 2.3% of all deaths.[vii]
There is a wide range of adult smoking rates extending from 3.4% in Ethiopia to 26.2% in Lesotho (see figure) but it should be noted that mapping the use of tobacco and nicotine products is patchy.
Smoking is predominantly a male habit and there are substantial differences in smoking rates between men and women. Lesotho has one of the highest adult male smoking rates globally at 52%, compared with less than 1% for women.[viii] Other countries with significant gender differences include Madagascar (39.5% m, 1.7% f), Mauritius (39.9% m, 3.7% f), and South Africa (34.3% m, 7.1% f)
The cost of a 20-stick cigarette pack ranges from US$1 to US$5 across 15 West African countries.[ix]
Tobacco control
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.
The WHO promotes the MPOWER tobacco control programme, the first letter of which refers to Monitoring, and one of its aims is to collect up-to-date information on the use of tobacco and related products. This is an extremely difficult task for many African countries due to the cost, and the measurement of SNP use is almost non-existent. Indeed, survey data on the use of nicotine vaping products are only available for Uganda.
Availability and legal status of safer nicotine products
There is a marked lack of information about the availability of SNP on the market, except in the case of nicotine replacement therapy (NRT). NRT is marketed in 18 countries and not marketed in 25, with no information available for five countries.
There are no specific laws regarding the use and sale of safer nicotine products in most countries in the region.
Sale of snus is allowed in 22 countries, while there is no specific law for 26.
For nicotine vaping products (e-cigarettes), there is no specific law for 38 countries, they are allowed under law in five countries and sale is banned in five. In Ethiopia, Uganda, Gambia, Seychelles and Mauritius, electronic cigarettes are legal to use but illegal to sell[x] though in 2019 the Seychelles government announced its intention to lift the ban and regulate electronic cigarettes.
In the case of heated tobacco products, there are no specific laws for 44 countries, sale is allowed under law in three countries and banned in just one.
In October 2020, the Kenyan government suspended the sale of LYFT nicotine pouches in order to review regulation. Since then, anti-tobacco harm reduction activists in Kenya have been pushing for either a complete ban of the product or for it to be regulated as a tobacco product (despite it not containing tobacco).
Legal and regulatory status of safer nicotine products
Nicotine vaping products (e-cigarettes)
Snus
Heated Tobacco Products
Kenya is the only country that has introduced a tax on electronic cigarettes. The tax is 3,000 Kenyan shillings (around US$30) per e-cigarette device and 2,500 Kenyan shillings per cartridge[x] while the minimum wage in the country is US$125 per month.
Some stakeholders in South Africa have been pushing for heavy tax measures to mirror what has happened in Kenya. In January 2022, the National Treasury published a discussion paper outlining a proposal on the taxation of electronic nicotine and non-nicotine delivery systems (ENDS) which was made open for public comment.[xii] The draft Control of Tobacco Products and Electronic Delivery Systems bill regulates electronic cigarettes in the same way as cigarettes.
Progress with THR
The concept of tobacco harm reduction has begun to take root across Sub-Saharan Africa thanks to the growing voice of THR advocacy.
There are tobacco harm reduction advocacy groups in Burkina Faso, the Democratic Republic of the Congo (DRC), Kenya, Malawi, Nigeria, South Africa, Uganda and Zambia. There is also a pan-African umbrella group – the Campaign for Safer Alternatives.[xiii] THR groups in these countries advocate for the availability and accessibility of safer nicotine products while also disseminating scientifically accurate information on nicotine consumption.
Through its Tobacco Harm Reduction Scholarship Programme (THRSP),[xiv] K•A•C has supported 35 people from the region to undertake a range of THR projects. These have included a documentary film exploring attitudes to smoking and tobacco harm reduction in Malawi, the establishment of a number of country-specific THR websites providing accurate information about both smoking and SNP, and a study to assess the feasibility of switching female smokeless tobacco users in rural areas in Malawi to snus. Other Scholars have conducted toxicological assessments of oral smokeless tobaccos that could aid smoking cessation and provided specialist training to community tobacco harm reduction champions in one of Nairobi’s slums.
Obstacles to THR adoption and implementation in Sub-Saharan Africa
Despite making some headway, there are a number of obstacles that affect the adoption and implementation of tobacco harm reduction in Sub-Saharan Africa.
Lack of affordable, acceptable and appropriate SNP. The availability and accessibility of safer nicotine products like electronic cigarettes, HTP and NRT remain poor in many LMIC. Where available, the products are limited in supply and their prices are too high for an average smoker.
Weak healthcare systems. Due to underfunding and neglect, some governments are unable to meet the basic requirements for a good healthcare system.[xv] Consequently, smokers have 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.[xvi] However, national mental health policies in many countries in the region do not directly address smoking in these populations.
Reliance on the international health establishment and misinformation. Because many countries in Africa have limited financial resources and/or lack the sustained political will to do otherwise, there is a heavy reliance on the WHO’s 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.[xvii] [xviii] 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.
Lack of awareness of THR. 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.
Opportunities and challenges for the future of THR in Sub-Saharan Africa
Most African countries have only minimal – if any – resources for tobacco control. But tobacco harm reduction is a low-cost intervention for governments since the research and development costs are borne by manufacturers and the purchase costs are met by consumers. In addition, as well as helping smokers to become smoke-free, SNP have the potential to prevent the uptake of smoking in the first place.
Progress in Africa is hampered by misinformation about SNP by the WHO, neo-colonial organisations pushing a ‘Western’ tobacco control solution,[xix] and tobacco companies neglecting to develop and market suitable products. 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 companies have paid little attention to the needs of the majority of smokers living in LMIC to help them shift to safer products.
The question is, what are the appropriate, accessible, affordable and acceptable THR products for African countries? There needs to be a wide range of SNP available.
One of the opportunities arises from the fact that smokeless tobacco has been used in the continent for centuries. This suggests that low-risk oral products (snus and nicotine pouches) could play an important role. Snus and nicotine pouches are low-tech, simple to use, don’t require electricity, are relatively cheap and environmentally friendly. Swedish-style snus could be made using locally grown tobacco. Snus could therefore generate income for small-scale tobacco growers who otherwise face an uncertain future, while simultaneously offering consumers an affordable and significantly safer alternative to traditional smokeless products. Only one company in the region has so far diversified its product line by offering oral nicotine pouches. LYFT pouches (marketed by BAT) were available in Kenya until sales were suspended in 2020.
Looking to the future, an approach to reducing smoking that includes a wide range of THR products would provide governments in the region with the tools to significantly improve health outcomes at minimal cost. Governments should regulate SNP appropriately, ensuring that higher risk tobacco products are always less economically attractive.
For further information about the Global State of Tobacco Harm Reduction’s work, or the points raised in this GSTHR Briefing Paper, please contact [email protected]
About us: Knowledge·Action·Change (K·A·C) promotes harm reduction as a key public health strategy grounded in human rights. The team has over forty years of experience of harm reduction work in drug use, HIV, smoking, sexual health, and prisons. K·A·C runs the Global State of Tobacco Harm Reduction (GSTHR) which maps the development of tobacco harm reduction and the use, availability and regulatory responses to safer nicotine products, as well as smoking prevalence and related mortality, in over 200 countries and regions around the world. For all publications and live data, visit https://gsthr.org
Our funding: The GSTHR project is produced with the help of a grant from the Foundation for a Smoke-Free World, a US non profit 501(c)(3), independent global organization. The project and its outputs are, under the terms of the grant agreement, editorially independent of the Foundation.
[i] World Health Organization. (2021). WHO global report on trends in prevalence of tobacco use 2000-25, fourth edition. Pp 19 and 25. Geneva. https://www.who.int/publications/i/item/9789240039322
[ii] World Bank. (2022). GDP (current US$) Sub-Saharan Africa. Retrieved March 4, 2022, from https://data.worldbank.org/indicator/NY.GDP.MKTP.CD?locations=ZG
[iii] World Bank. (2022). GDP per capita (current US$). Retrieved March 4, 2022, from https://data.worldbank.org/indicator/NY.GDP.PCAP.CD?end=2020&start=1960&view=chart
[iv] World Health Organization. (2021). Status of Tobacco Production and Trade in Africa. https://www.who.int/publications/i/item/9789240020009
[v] Duvall, C. S. (2017). Cannabis and Tobacco in Precolonial and Colonial Africa. Oxford Research Encyclopedia of African History. https://doi.org/10.1093/acrefore/9780190277734.013.44
[vi] World Health Organization. (2021). WHO global report on trends in prevalence of tobacco use 2000-2025, fourth edition. P.24. Geneva https://www.who.int/publications/i/item/9789240039322
[vii] Drope, J., Schluger, N., Cahn, Z., Drope, J., Hamill, S., Islami, F., Liber, A. C., Nargis, N., & Stoklosa, M. (2018). The Tobacco Atlas (6th ed.). American Cancer Society and Vital Strategies. https://tobaccoatlas.org/
[viii] Knowledge Action Change. (2021). Global State of Tobacco Harm Reduction. Tobacco smoking in Lesotho. https://gsthr.org/ countries/profile/lso/1/
[ix] Statista. (2021). Price of a pack of cigarettes in West Africa between 2008 and 2018, by country. https://www.statista.com/statistics/1280085/price-of-a-pack-of-cigarettes-by-country/
[x] The Indian Express. (2019). E-cigarettes: Here is the legal stand other countries have taken on vaping. https://indianexpress.com/article/world/ecigarette-laws-vaping-ban-global-5776433/
[xi] The University of the Witwatersrand, Johannesburg. (2020). Many countries regulate e-cigarettes. South Africa should too. https://www.wits.ac.za/news/latest-news/opinion/2020/2020-01/many-countries-regulate-e-cigarettes-south-africa-should-too.html
[xii] BusinessTech. (2022). New vaping rules and taxes planned for South Africa. https://businesstech.co.za/news/lifestyle/548328/new-vaping-rules-and-taxes-planned-for-south-africa/
[xiii] Campaign for Safer Alternatives (CASA). https://safer-alternatives.org/
[xiv] Tobacco Harm Reduction Scholarship Programme (THRSP). https://thrsp.net/
[xv] Oleribe, O. E., Momoh, J., Uzochukwu, B. S., Mbofana, F., Adebiyi, A., Barbera, T., Williams, R., & Taylor Robinson, S. D. (2019). Identifying Key Challenges Facing Healthcare Systems in Africa And Potential Solutions. International Journal of General Medicine, Volume 12, 395–403. https://doi.org/10.2147/ijgm.s223882
[xvi] National Institute on Drug Abuse. (2020). Tobacco, Nicotine, and E-Cigarettes Research Report: Do people with mental illness and substance use disorders use tobacco more often? https://www.drugabuse.gov/publications/research-reports/tobacconicotine-e-cigarettes/do-people-mental-illness-substance-use-disorders-use-tobacco-more-often
[xvii] Knowledge Action Change. (2020). Global State of Tobacco Harm Reduction. Burning Issues. Chapter 5, Project Fear: the war against nicotine. https://gsthr.org/reports/burning-issues-2020/chapter-5/
[xviii] Knowledge Action Change. (2021). Global State of Tobacco Harm Reduction. GSTHR Briefing Paper: Fighting the Last War: the WHO and International Tobacco Control. https://gsthr.org/briefing-papers/fighting-the-last-war-the-who-and-internationaltobacco-control/
[xix] Knowledge Action Change. (2020). Global State of Tobacco Harm Reduction. Burning Issues. Chapter 5, Project Fear: the war against nicotine. https://gsthr.org/reports/burning-issues-2020/chapter-5/