It is estimated that worldwide, about 6 million people die from tobacco use each year, both from direct tobacco use and second-hand tobacco smoke (SHS).⁽²⁾ Most of those deaths occur in low- and middle-income countries.⁽³⁾ SHS, or environmental tobacco smoke (ETS), is the combination of smoke emitted from the burning end of a cigarette or from other tobacco products and smoke exhaled by the smoker.⁽⁴⁾ Exposure to tobacco smoke, also known as second-hand smoking, is as deadly as smoking itself. In 2004, SHS caused 603,000 premature deaths, of which 47% were women, 28% children and 26% men.⁽⁵⁾ Exposure usually occurs in homes, workplaces, public transportation and public places.

Exposure to SHS is completely avoidable. Evidence suggests that implementing 100% smoke-free environments is the only effective way to protect populations.(6) Studies conducted after implementation of smoke-free policies have revealed that smoke-free laws decrease exposure to SHS by 80–90%.⁽⁷⁾ Smoke-free policies reduce exposure to SHS; they save lives, prevent illness and disabilities; they are cost-effective; they are supported by the public and are relatively easy to implement with adequate planning and resources; they help smokers to quit and they reduce youth smoking initiation.⁽⁸⁾

Worldwide, there is a global momentum for smoke-free policies and tremendous successes have been achieved. In many African countries like South Africa, Mauritius and Seychelles it is now illegal to smoke in public places such as hospitals, restaurants and pubs. However, smoke-free laws are not always enforced. This article identifies the obstacles and challenges to the adoption and implementation of smoke-free policies in Africa.

Health effects of exposure to SHS

The World Health Organisation (WHO) has stated that “There is no safe level of exposure to SHS.”⁽⁹⁾ Over the years, the International Agency for Research on Cancer (IARC), the United States Surgeon General, the United States Environmental Protection Agency (EPA) and the WHO, among many experts, have documented the adverse effects of SHS on respiratory and circulatory systems, its role as a carcinogen in adults, and its impact on children’s health and development.⁽¹⁰⁾ Some of these are listed in Table 1.

Table 1: Health effects of SHS on adults and children ⁽¹¹⁾

WHO Framework Convention on Tobacco Control

The WHO Framework Convention on Tobacco Control (WHO FCTC) is the first treaty negotiated under the auspices of the WHO.⁽¹²⁾ It is an evidence-based treaty that was developed in response to the globalisation of the tobacco epidemic.⁽¹³⁾ The treaty provides tobacco control measures to reduce both the demand for and the supply of tobacco. Article 8 of the WHO FCTC addresses the issue of second-hand smoking.

Article 8 of the WHO FCTC: Protection from exposure to tobacco smoke

Article 8 of the WHO FCTC states:

1. Parties recognize that scientific evidence has unequivocally established that exposure to tobacco smoke causes death, disease and disability.
2. Each Party shall adopt and implement in areas of existing national jurisdiction as determined by national law and actively promote at other jurisdictional levels the adoption and implementation of effective legislative, executive, administrative and/or other measures, providing for protection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places and, as appropriate, other public places.⁽¹⁴⁾

Article 8 includes the following core principles for effective smoke-free policies:⁽¹⁵⁾

1. Eliminate tobacco smoke to create 100% smoke-free places.
2. Protect everyone – don’t allow exemptions.
3. Use legislation, not voluntary measures.
4. Provide resources for implementing and enforcing the law.
5. Include civil society as an active partner.
6. Monitor and evaluate smoke-free laws.
7. Be prepared to amend the law if needed.

Implementation of article 8 in Africa: Major challenges

The following have been identified in the literature as the major challenges faced by the tobacco control community in Africa.

Tobacco industry interference: The tobacco industry has been designated the “vector” of the global tobacco epidemic. Multinational tobacco companies oppose smoke-free policies by any means because of the large sums of money they may lose if the laws are successfully implemented.⁽¹⁶⁾ Furthermore, the tobacco industry influences the media. In Senegal, for instance, the industry has the support of the media which is in favour of tobacco advertising.⁽¹⁷⁾ In Nigeria, British American Tobacco (BAT) runs an annual competition for journalists covering the company, and has also hosted lavish meetings for media executives and journalists, who received gifts to attend.⁽¹⁸⁾ In addition, the tobacco industry maintains close relationships with legislators and government officials. In Zambia, BAT used its close relationship with a government minister to shape the country’s smoke-free laws and dilute proposals for smoke-free legislation. At a BAT-sponsored event, the minister announced her support for smoking zones, which were not included in the legislation.⁽¹⁹⁾ In other instances, the tobacco industry went as far as challenging the anti-smoking legislation in court in order to either delay the implementation of the law or overturn or weaken it.⁽²⁰⁾ In 2008, BAT Kenya and Mastermind Tobacco launched legal action against the Kenyan Government’s Tobacco Control Act, which included smoke-free provisions, thereby threatening the legislation.⁽²¹⁾

Lack of political will: In some African countries, there is a lack of political will among government officials and members of parliament in implementing smoke-free policies. As a result, not only is the process of adopting smoke-free policies slowed down, but the policies are also not implemented in an efficient manner, with populations left unprotected.⁽²²⁾

Insufficient financial and human resources: The availability of resources, not only to change policy, but also to implement and enforce new laws, is a major issue; most African countries still rely on donors for external assistance.⁽²³⁾ Another challenge is conflicting priorities on a continent where the HIV/AIDS pandemic usually attracts all the available resources. Similar to lack of funds, there is the issue of corruption of enforcement officers or inspectors.⁽²⁴⁾

Civil society involvement: Civil society can intervene in the development, implementation and defence of smoke-free policies.⁽²⁵⁾ They can play a key role in encouraging compliance with smoke-free laws, by educating enforcement agencies, decision makers, the media and the public.⁽²⁶⁾ However, in some African countries, civil society is weak, or poorly involved in the process, or simply lacks the resources necessary to effectively play its role.⁽²⁷⁾

Lack of public awareness: The public often lacks information concerning the dangers of exposure to tobacco smoke and the existence of laws which ensure their protection, or can be misinformed by the tobacco industry through manipulation of the media, hence the need for awareness campaigns.⁽²⁸⁾

Enforcement challenges: After passing smoke-free policies, in order to maintain high compliance, specific structures are necessary to effectively implement the legislation, with well-trained and equipped staff and a budget, mandated by the law. The availability and/or willingness of officials to enforce the smoke-free policies, along with appropriate training and resources to ensure that they are adequately equipped to do their jobs, are key elements to successfully implementing adopted smoke-free laws.⁽²⁹⁾ In 2003, Tanzania passed major tobacco control legislation, but enforcement continues to be an enormous challenge. The legislation calls explicitly for health supervisors to enforce the law, but these officials have never been selected nor empowered by subsequent regulation.⁽³⁰⁾ In Kenya, enforcement officers reported insufficient resources for the execution of their duties and a lack of coordination between public health officers and the police in enforcement, particularly for facilitating arrests.⁽³¹⁾ The numbers of personnel allocated for the task can be insufficient, as it is the case in Mauritius where there are thousands of public environments and workplaces that fall under the tobacco control regulations.⁽³²⁾

Poor monitoring and surveillance systems: A proper assessment of the implementation and effectiveness, or lack thereof, of smoke-free policies must be done through monitoring and evaluation. However, many African countries are struggling in that area. Due to insufficient resources, African countries lack the capacity to conduct proper studies to evaluate the real impact of smoke-free policies after enactment of the legislation. Only a few countries, like South Africa, have efficient mechanisms to monitor and evaluate tobacco prevalence as well as tobacco-related morbidity and mortality. Therefore, evaluating the impact of smoking bans remains a challenge.⁽³³⁾ An assessment that was done in the Seychelles to evaluate the implementation of smoke-free laws in hospitality venues did not require the use of expensive methods.⁽³⁴⁾ The study design used in the Seychelles, simple and inexpensive, can easily be reproduced in other low and middle-income countries.

Concluding remarks

The South African economist, Evan Blecher, predicted that tobacco consumption will double in the next 12 to 13 years in Sub-Saharan Africa - unless anti-smoking policies are adopted.⁽³⁵⁾ Besides impoverishing families, an increase in the consumption rate will result in an increase in disease burden that will generate unaffordable health costs. Implementing smoke-free policies stands out as the solution to avoid such a public health disaster.

In Africa, countries such as Mauritius, South Africa and Seychelles are tobacco control models in terms of implementing smoke-free policies which are FCTC-compliant. Other African countries still have a long way to go. Nevertheless, tobacco control communities strive relentlessly to achieve efficient protection of populations against SHS.

Tobacco industry interference, insufficient financial and human resources, lack of support from government officials and legislators and poor involvement of civil society are among the barriers to achieving a smoke-free Africa. However, poor compliance, as well as poor, often non-existent enforcement and monitoring and surveillance systems are the real threats to smoke-free laws in Africa as identified in this review. Therefore, there is a crucial need for efficient implementation strategies, along with proper monitoring and surveillance systems on the one hand; and on the other, a need for scientific research in order to evaluate the effectiveness of smoke-free policies in Africa.

Written by Patrick Ngassa Piotie ⁽¹⁾

NOTES:

(1) Contact Patrick Ngassa Piotie through Consultancy Africa Intelligence’s Public Health Unit ( public.health@consultancyafrica.com). This CAI discussion paper was developed with the assistance of Claire Furphy and was edited by Liezl Stretton.
(2) ‘Implementing smoke-free environments’, World Health Organization report on the global tobacco epidemic, 2009, http://www.who.int.
(3) Ibid.
(4) Ibid.; ‘Protection from exposure to second-hand tobacco smoke. Policy recommendations’, World Health Organization, 2007, http://www.who.int.
(5) Oberg, M., et al., 2011. Worldwide burden of disease from exposure to second-hand smoke: A retrospective analysis of data from 192 countries. The Lancet, 377(9760), pp.139-146.
(6) ‘Protection from exposure to second-hand tobacco smoke. Policy recommendations’, World Health Organization, 2007, http://www.who.int.
(7) ‘Implementing smoke-free environments’, World Health Organization report on the global tobacco epidemic, 2009, http://www.who.int.
(8) Ibid.
(9) ‘Protection from exposure to second-hand tobacco smoke. Policy recommendations’, World Health Organization, 2007, http://www.who.int.
(10) Ibid.
(11) McNeill, A., 2004. “Tobacco use and effects on health”, inTobacco or health in the European Union – past, present and future. Office for Official Publications of the European Communities: Luxembourg.
( 2) ‘WHO Framework Convention on Tobacco Control’, World Health Organization, 2003 (updated 2004, 2005), http://www.who.int.
( 3) Ibid.
( 4) Ibid.
( 5) ‘Article 8 status report’, Global Smokefree Partnership, 2010, http://www.globalsmokefreepartnership.org.
( 6) ‘Global Voices report: Rebutting the tobacco industry, winning smokefree air’, Global Smokefree Partnership, 2009, http://www.globalsmokefreepartnership.org; Baleta, A., 2010. Africa’s struggle to be smoke free. The Lancet, 375, pp. 107-108.
( 7) Diagne, A. and Mboup, B., 2011. “Senegal”, in Drope, J. (ed). Tobacco control in Africa. People, politics, policies (1st edition). Anthem Press: London and New York.
( 8) ‘Global Voices report: Rebutting the tobacco industry, winning smokefree air’, Global Smokefree Partnership, 2009, http://www.globalsmokefreepartnership.org.
( 9) Ibid.; Baleta, A., 2010. Africa’s struggle to be smoke free. The Lancet, 375, pp. 107-108.
(20) ‘Global Voices report: Rebutting the tobacco industry, winning smokefree air’, Global Smokefree Partnership, 2009, http://www.globalsmokefreepartnership.org.
(21) Ibid.
(22) Drope, J., 2011. Tobacco control in Africa. People, politics, policies (1st edition). Anthem Press: London and New York.
(23) Ibid.; Owusu-Dabo, E., et al., 2010. Status of implementation of Framework Convention on Tobacco Control (FCTC) in Ghana: A qualitative study. BMC Public Health, 10, pp. 1, http://www.biomedcentral.com.
(24) Drope, J., 2011. Tobacco control in Africa. People, politics, policies (1st edition). Anthem Press: London and New York.
(25) Griffith, G., et al., 2010. Implementation of smokefree workplaces: Challenges in Latin America. Salud Publica de Mexico, 52(suppl 2), pp. S347-S354.
(26) ‘Article 8 status report’, Global Smokefree Partnership, 2010, http://www.globalsmokefreepartnership.org; Asare, B.E., 2009. Tobacco regulation in South Africa: Interest groups and public policy. African Journal of Political Science and International Relations, 3(3), pp. 99-106.
(27) Drope, J., 2011. Tobacco control in Africa. People, politics, policies (1st edition). Anthem Press: London and New York; Griffith, G., et al., 2010. Implementation of smokefree workplaces: Challenges in Latin America. Salud Publica de Mexico, 52(suppl 2), pp. S347-S354.
(28) ‘Global Voices report: Rebutting the tobacco industry, winning smokefree air’, Global Smokefree Partnership, 2009, http://www.globalsmokefreepartnership.org; Drope, J.M., 2010. The politics of smoke-free policies in developing countries: Lessons from Africa. CVD Prevention and Control, 5(3), pp. 65-73.
(29) ‘Global Voices report: Rebutting the tobacco industry, winning smokefree air’, Global Smokefree Partnership, 2009, http://www.globalsmokefreepartnership.org; Owusu-Dabo, E., et al., 2010. Status of implementation of Framework Convention on Tobacco Control (FCTC) in Ghana: A qualitative study. BMC Public Health, 10, pp. 1, http://www.biomedcentral.com; Griffith, G., et al., 2010. Implementation of smokefree workplaces: Challenges in Latin America. Salud Publica de Mexico, 52(suppl 2), pp. S347-S354.
(30) Drope, J., 2011. Tobacco control in Africa. People, politics, policies (1st edition). Anthem Press: London and New York.
(31) Ibid.
(32) Ibid.
(33) Swart, D. and Panday, S., ‘The surveillance and monitoring of tobacco control in South Africa’, World Health Organization, 2003, http://www.who.int.
(34) Viswanathan, B., et al., 2011. Impact of a smoking ban in public places: A rapid assessment in the Seychelles. Tobacco Control,20(6), pp. 427-430.
(35) Baleta, A., 2010. Africa’s struggle to be smoke free. The Lancet, 375, pp. 107-108.