Tobacco Control in Africa This page intentionally left blank Tobacco Control in Africa People, Politics and Policies Edited by Jeffrey Drope International Development Research Centre Ottawa • Cairo • Dakar • Montevideo • Nairobi • New Delhi • Singapore Anthem Press An imprint of Wimbledon Publishing Company www.anthempress.com This edition fi rst published in UK and USA 2011 by ANTHEM PRESS 75-76 Blackfriars Road, London SE1 8HA, UK or PO Box 9779, London SW19 7ZG, UK and 244 Madison Ave. #116, New York, NY 10016, USA A copublication with the International Development Research Centre PO Box 8500, Ottawa, ON K1G 3H9, Canada www.idrc.ca / [email protected] ISBN: 978 1 55250 510 6 (eBook) © 2011 Jeffrey Drope editorial matter and selection; individual chapters © individual contributors The moral right of the authors has been asserted. All rights reserved. Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording or otherwise), without the prior written permission of both the copyright owner and the above publisher of this book. British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library. Library of Congress Cataloging-in-Publication Data The Library of Congress has cataloged the hardcover edition as follows: Tobacco control in Africa : people, politics, and policies / edited by Jeffrey M. Drope. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-85728-783-0 (hardback : alk. paper) ISBN-10: 0-85728-783-4 (hardback : alk. paper) I. Drope, Jeffrey M. [DNLM: 1. Smoking–prevention & control–Africa South of the Sahara. 2. Health Policy–Africa South of the Sahara. 3. Smoking–legislation & jurisprudence–Africa South of the Sahara. 4. Tobacco Industry–legislation & jurisprudence–Africa South of the Sahara. HV 5740] LC classifi cation not assigned 362.29’6096–dc23 2011032528 ISBN-13: 978 0 85728 437 2 (Pbk) ISBN-10: 0 85728 437 1 (Pbk) This title is also available as an eBook. CONTENTS List of Figures and Tables vii Foreword ix Preface xi Acknowledgments xv List of Abbreviations and Acronyms xix 1. Introduction 1 2. The Political Mapping Process 13 3. Progress on Smoke-Free Policies 29 4. Taxation as a Tobacco Control Strategy 43 5. The Challenges of Implementing Bans on Advertising, Promotion and Sponsorship 63 6. The Pursuit of Packaging and Labeling Requirements 79 7. Burkina Faso 97 8. Cameroon 107 9. Eritrea 123 10. Ghana 135 11. Kenya 149 12. Malawi 167 13. Mauritius 185 14. Nigeria 201 15. Senegal 219 vi TOBACCO CONTROL IN AFRICA 16. South Africa 227 17. Tanzania 247 18. Zambia 261 19. Conclusion: Tobacco Control in Africa – People, Politics and Policies 283 Notes on Contributors 295 Index 299 LIST OF FIGURES AND TABLES Figures Figure 9.1 Eritrean tobacco production by value, 1995–2006 131 Figure 10.1 Ghana GYTS 2005 prevalence highlights 138 Figure 16.1 Cigarette price and consumption in South Africa, 1992–2001 236 Tables Table 3.1 Status of smoke-free policies in the 12 ATSA countries 30 Table 4.1 Affordability of a 20-cigarette pack of the most widely consumed brand 46 Table 4.2 National tobacco taxes – 2009–10 50 Table 5.1 Status of advertising, promotion and sponsorship requirements and prohibitions in the 12 ATSA countries 66 Table 5.2 Youths and tobacco in the 12 ATSA countries 74 Table 6.1 Packaging and labeling provisions in the 12 ATSA countries 80 Table 8.1 Manufactured tobacco production in Cameroon (tons) 118 Table 8.2 Tobacco imports and exports in Cameroon 118 Table 8.3 Customs and excise duties on imported tobacco in Cameroon (CFAF, millions) 119 Table 8.4 Taxes on domestic tobacco production in Cameroon (CFAF, millions) 119 Table 9.1 Eritrean tobacco consumption by product type, 2000 131 viii TOBACCO CONTROL IN AFRICA Table 13.1 Mauritius prevalence rates – NCD surveys 188 Table 13.2 Mauritius prevalence rates by age groups 188 Table 16.1 Daily adult smoking prevalence rates by “race” and gender in South Africa, 2008 230 Table 16.2 Tobacco farming in South Africa – 2000 versus 2007 241 Table 18.1 Zambia – Most recent national prevalence rates 264 Table 18.2 Ranking of six public health programs in Zambia, 2008 280 Foreword TOBACCO CONTROL IN AFRICA – PEOPLE, POLITICS AND POLICIES This magnum opus on tobacco control in Africa could not be timelier as we begin to confront the next global epidemic of noncommunicable diseases. Its 19 chapters and 12 country situational analyses carry the message effectively for all those who care to listen – governments, industry, health professionals and most poignantly of all, consumers, particularly today’s youth. As this is a book on the African odyssey relating to a dreaded risk factor to health in world history, two timeless African proverbs seem apposite: • “The choreographer has given birth to her child; it not remains for the child to know how to dance.” That is, there is no longer any excuse for not knowing how to proceed. • “To prevent the branch of the tree sticking out dangerously from hurting your eyes, you must begin to contemplate that possibility from afar.” The epidemic is already upon us, not looming, so we must act now. Anti-smoking policies have been developed and strategies mounted at global, regional and country levels, but the tepid response and lackluster attention paid to implementation have continued to thwart our efforts. The political will has not yet been consummated, and the shifting of the theater of “war” and skillful manipulation of unsuspecting nations by the tobacco industry continue to exact hardship on the expected impact on tobacco control. Yet populations are acutely aware of the pervasive and devastating complications of the short- and long-term use of tobacco. A few may be ignorant, but many are simply indifferent or even defi ant. The politics of tobacco control is a complex one: the lobby is often strong and determined, but at one point or other it meets with an equally powerful pro-tobacco counterlobby. In a corrupt political system it is easy to guess which side eventually triumphs. Twelve countries in Africa have been appraised out of a total of over fi fty, but the fi ndings apply to the rest mutatis mutandis. But as the concluding chapter emphasizes, the approach varies with the social, political and economic x TOBACCO CONTROL IN AFRICA environment and the solution cannot be “one size fi ts all.” At the end of the day, political leadership is the most powerful activator for change and its impact on social, lifestyle, habit, environmental and economic integrity will determine whether a country is winning or losing this battle. Africa has a responsibility to resist the carrot of industrial temptation. History will judge leaders harshly, including the health professions themselves, if we continue – like the proverbial ostrich – to bury our heads in the sand. The solution demands a doggedness that must permit us to shun quick returns and instead to focus on long-term gains, the types of dividends in human health that we cannot begin to compare with material resources. The developed world has devised its own approach and the wily industrialists in the tobacco camp have relocated to the less-developed world, knowing that the index of compromise in this new environment is high. They increasingly dazzle the economically weak with ephemeral incentives. Impoverished populations must hold their destinies in their hands and hearken to the remonstrating cries of those in their indigenous communities who never tire of explaining the ruinous effects of tobacco on health. Advice, like water constantly dripping, will eventually wear away stone. I warmly recommend this monumental work – a true vade mecum – to all stakeholders, policymakers and real and potential consumers in the African setting. Dr Jeffrey Drope and his team must be congratulated for putting together a compendium that clearly addresses the various facets of this problem. It is a compelling read and a clarion wakeup call, and I hope that the “Doubting Thomases” on the continent will no longer be content to sit on the fence. O. O. Akinkugbe, MD, PhD Emeritus Professor of Medicine University of Ibadan, Nigeria October 2010 PREFACE In recent years the tobacco control community has shifted its focus to low- and middle-income countries (LMICs), which are becoming a major market for tobacco companies seeking to expand their profi ts and compensate for dwindling markets in higher-income countries. While some LMICs already have alarming smoking prevalence levels, many currently hover on the cusp of the epidemic. Such is the case in much of Sub-Saharan Africa (SSA). Already burdened by infectious diseases, the region now faces the extra burden of noncommunicable diseases related to tobacco use. The goal is to prevent another epidemic. This objective raises unique challenges in an area where the negative health effects of tobacco use are not yet widespread and where governments do not yet consider tobacco control as a health or development priority. Attracted to the notion of staving off another epidemic in SSA, the Bill and Melinda Gates Foundation and the International Development Research Centre (IDRC) partnered in the fall of 2007 to analyze the status of the tobacco problem in a number of SSA countries, and to identify those countries in which an intervention might be most effective. The original plan was to conduct situational analyses in these countries; that is, to gather all existing data on current tobacco use, tobacco farming, tobacco control policies and the key players involved in the fi eld. African researchers would gather, synthesize and analyze data at the country level so that local governments, civil society, universities and potential funders could use this information to understand opportunities for and obstacles to tobacco control, as well as the capacity for action in each country.