Smoking Prevalence and Tobacco Control Measures in Kenya, Uganda, the Gambia and Liberia: a Review

Smoking prevalence and tobacco control measures in Kenya, Uganda, the Gambia and Liberia: a review

E. M. Nturibi,* A. A. Kolawole,† S. A. McCurdy‡ * Kenya Association for Prevention of Tuberculosis and Lung Disease (KAPTLD), Nairobi, Kenya; † Medical Research Council Laboratories, Basse, the Gambia; ‡ Division of Environmental and Occupational Health, Department of Public Health Sciences, University of California, Davis, California, USA

SUMMARY

BACKGROUND: Smoking prevalence is increasing in de- RESULTS: We noted a high prevalence of smoking in veloping countries. These resource-poor countries will Kenya, Uganda and the Gambia. There were no published have to battle tobacco-related diseases before they have data on tobacco use prevalence for Liberia. Tobacco con- eliminated common communicable diseases. trol measures were inadequate. METHODS: We conducted a computerised search of CONCLUSION: Standardised prevalence studies involv- PubMed to identify published estimates of smoking prev- ing general populations should be conducted. Tobacco alence in Kenya, the Gambia, Uganda and Liberia. We control efforts need to be reinforced. also reviewed tobacco control measures in each country KEY WORDS: tobacco; prevalence; control; Kenya; using information provided by the respective health Uganda; Liberia; the Gambia departments.

IN 1971, the British Medical Journal warned that the of tobacco needed to be emphasised, e.g., the loss of deadly habit of smoking may spread to Africa and that capacity for foreign trade in essential goods and the this would have dire consequences.1 Today, massive extensive deforestation occurring to fuel the fl ue marketing campaigns by transnational tobacco com- curing of tobacco’. Moreover, alternative sources of panies have led to an epidemic of enormous propor- livelihood should be sought for countries with tions, with young people its most vulnerable target.2,3 tobacco-dependent economies, such as Zimbabwe Between 1995 and 2000, total cigarette consumption and Malawi.7 in the sub-Saharan region increased by 38.4%, from Data on smoking prevalence in sub-Saharan Africa 131 181 million sticks to 212 788 million sticks.4 It is are scarce. A report from the World Bank showed projected that by 2030, 70% of the estimated 10 mil- that of only 13 countries that had available data in lion global deaths from tobacco will occur in devel- Africa, Egypt had the highest prevalence of smoking oping countries whose resources are spent battling among adult males and females (respectively 40% human immunodefi ciency virus/acquired immune- and 18%) and Ethiopia the lowest (respectively 6% defi ciency syndrome (HIV/AIDS) and numerous other and <0.5%). These rates are comparable to those of communicable diseases. The ‘addition of tobacco- industrialised countries such as the United States (re- related diseases creates an unprecedented calamity spectively 24% and 19%) and the United Kingdom for public health’.5 The World Health Organization (respectively 27% and 25%). 6 (WHO) predicts that smoking-related diseases will Tobacco control efforts in sub-Saharan Africa are appear in developing countries before communicable rudimentary. A report on tobacco use in the Africa diseases and malnutrition have been controlled, fur- region noted that only South Africa, Botswana, Mali ther widening the health gap between rich and poor and Mauritius had comprehensive anti-tobacco laws countries.6 that draw from key principles such as taxation, ad- The 1993 All Africa Conference on Tobacco Con- vertising bans, smoking restrictions and effective ces- trol noted that although the health hazards of smok- sation and education programmes. It was worthy of ing are generally understood in the West, these argu- note that 50% of countries in sub-Saharan Africa had ments have had little impact on poorer nations. The no form of regulation on tobacco advertising in the conference proposed that ‘more immediate ill effects media.4

Correspondence to: Eric Mugambi Nturibi, Kenya Association for Prevention of TB and Lung Disease (KAPTLD), P O Box 29774-00202/27789-00506, Nairobi, Kenya. Tel: (+254) 722 758 767. Fax: (+254) 020 272 9692. e-mail: mugambi@ kma.co.ke, [email protected] Article submitted 20 July 2008. Final version accepted 3 October 2008. 166 The International Journal of Tuberculosis and Lung Disease

METHODS We then reviewed legal tobacco control measures in each country based on information provided by We conducted a computerised search of the PubMed the national health departments (offi cial websites) literature database using the key words ‘tobacco use’ and the WHO website. followed by the country name (‘Kenya’, ‘the Gambia’ ‘Uganda’, and ‘Liberia’) to identify published estimates of smoking prevalence/tobacco use in the four RESULTS African countries. The search criteria yielded 39 articles on Kenya, 12 articles on Uganda and six articles Smoking prevalence on the Gambia. There were no results under ‘Liberia’. Table 1 summarises the prevalence of cigarette smok- The abstracts were carefully reviewed and eight ab- ing/tobacco use in Kenya, the Gambia and Uganda; stracts of original articles citing tobacco/cigarette use there were no published estimates for Liberia. prevalence were identifi ed. The full articles were then Lore’s survey on health care workers in Kenya reviewed and prevalence data summarised. reported a ‘current smoking’ prevalence of 54%, with We accessed the US Centers for Disease Control males predominating (63.9% of all subjects).8 Kwa- and Prevention (CDC) website and reviewed data from manga et al. found a prevalence rate among primary the Global Youth Tobacco Surveys (GYTS). The prev- school teachers of 50% in males and 3% in females alence data were extracted and summarised along (n = 813).9 Among undergraduate students, Odek et with the data from other surveys. al. found a lifetime prevalence of smoking of 54.7%

Table 1 Tobacco use in Kenya, the Gambia, Uganda, and Liberia

Smoking/tobacco-use Country, prevalence, % fi rst author, reference Year of survey Sample size, n, population Overall Male Female Comment Kenya 8 Lore 1988 672 health care 54* 63.9 7 Important study population as health workers workers key to tobacco control Kwamanga9 1996 813 primary school 50* 3 Important study population as teachers teachers have infl uence on young minds Odek et al.10 1999 558 undergraduate 54.7† Data not representative of the students general population Othieno11 2000 150 out-patients 56.4† 5.6 Cessation efforts may fare better in those who perceive themselves to be in poor health12 GYTS13 2001 4447 high school students 13‡ 15.8 10 School-based survey—smoking starts aged 13–15 years early and prevention can be focused here Standardised, held at regular intervals Includes use of other forms of tobacco The Gambia Walraven14 October 1996– 5389 adults ⩾15 years 34 urban 1.5 urban Rural and urban communities June 1997 42 rural 6 rural involved, thus fairly representative of the general population Maassen15 2004 282 schoolchildren 47.2 Survey restricted to schoolchildren aged 14–18 years 11.3 weekly Study focus was age at initiation of 3.9 monthly smoking and cognitive infl uences 32 less than monthly as opposed to prevalence per se Uganda GYTS16 2007 4268 high school students 16.6 national‡ 17.3 15.3 See comments under GYTS Kenya aged 13–15 years 15.6 Kampala 16.3 14.1 Mpabulungi17 2006 1528 high school 21.9§ 25.5 12.2 Study conducted in tobacco students, Arua growing area Mpabulungi18 2789 high school 5.3 current§ Important study population as peer students, Kampala 17.5 lifetime† infl uence is associated with smoking initiation Liberia No published data available

* Defi nitions of current smoking vary. Except where otherwise noted, current smoking is defi ned as those who answered yes to both questions ‘Have you smoked 100 cigarettes in your entire life?’ and ‘Are you still smoking now?’19 † Lifetime prevalence of smoking. ‡ Current use of any tobacco product. § Current smoking defi ned as having smoked at least once within the past 1 month. GYTS = Global Youth Tobacco Survey. Tobacco use and control in four African countries 167

(n = 558).10 Othieno et al. found a lifetime smoking Table 2 Current status of the WHO Framework Convention prevalence of 56.4% in males and 5.6% in females on Tobacco Control: sub-Saharan Africa20 among 150 attendees of an out-patient clinic.11 Country Signature date Ratiﬁ cation In the Gambia, Walvaren et al. carried out a survey Angola 29 June 2004 20 September 2007 among 5389 adults aged ⩾15 years. The prevalence Benin 18 June 2004 3 November 2005 of current smoking among males was 34% in urban Botswana 16 June 2003 31 January 2005 Burkina Faso 22 December 2003 31 July 2006 areas and 42% in rural areas. Among females, the Burundi 16 June 2003 22 November 2005 prevalence was 1.5% in urban areas and 6% in rural Cameroon 13 May 2004 3 February 2006 areas.14 Maasen et al. studied factors responsible for Central African Republic 29 December 2003 7 November 2005 smoking initiation among 282 Gambian adolescents. Chad 22 June 2004 30 January 2006 They noted a total smoking prevalence of 47.2%, Congo 23 March 2004 6 February 2007 with 32% smoking less than once monthly, 3.9% Cote d’Ivoire 24 July 2003 Democratic Republic smoking at least once per month and 11.3% smoking of Congo 28 June 2004 28 October 2005 on a weekly basis.15 Djibouti 13 May 2004 31 July 2005 In Uganda, Mpabulungi et al. studied high school Egypt 17 June 2003 25 February 2005 = Equatorial Guinea Not given 17 September 2005 students in the capital city, Kampala (n 2789), Eritrea* as well as in the rural tobacco growing town of Ethiopia 25 February 2004 Arua (n = 1528). In Kampala, they found a current Gabon 22 August 2003 Gambia 16 June 2003 18 September 2007 smoking prevalence of 5.3% compared to 21.9% in Ghana 20 June 2003 29 November 2004 Arua.17,18 Guinea 1 April 2004 The GYTSs carried out in Kenya (2001) and Guinea Bissau* Kenya 25 June 2004 25 June 2004 Uganda (2007) reported lifetime smoking prevalence Lesotho 23 June 2004 14 January 2005 rates of respectively 13% and 16.6% among 13- to Liberia 25 June 2004 15-year-old high school students.13,16 Libya 18 June 2004 7 June 2005 Madagascar 24 September 2003 22 September 2004 Malawi* Tobacco control measures in Kenya, the Gambia, Mali 23 September 2003 19 October 2005 Uganda and Liberia Mauritania 24 June 2004 28 October 2005 Morocco 16 April 2004 In October 2000, the Inter-country Meeting on To- Mozambique 18 June 2003 bacco Control Policy and Programming in the Africa Namibia 29 January 2004 7 November 2005 Niger 28 June 2004 25 August 2005 Region held in Nairobi, Kenya, recommended that Nigeria 28 June 2004 20 October 2005 African governments ‘advocate and mobilise support Rwanda 2 June 2004 19 October 2005 for the negotiation and ratifi cation of an evidence- Senegal 19 June 2003 27 January 2005 Sierra Leone* based Framework Convention on Tobacco Control South Africa 16 June 2003 19 April 2005 (FCTC)’.4 Table 2 shows the current status of the Sudan 10 June 2004 31 October 2005 WHO FCTC in sub-Saharan Africa.19 Swaziland 29 June 2004 13 January 2006 Tanzania 27 January 2004 30 April 2007 A summary of tobacco control measures in Kenya, Togo 12 May 2004 15 November 2005 the Gambia, Uganda and Liberia is shown in Table 3. Tunisia 22 August 2003 Limited data on Liberia were obtained from the WHO Turkey 28 April 2004 31 December 2004 Uganda 5 March 2004 20 June 2007 website.* Zambia* Kenya regulates six of seven provisions of the Zimbabwe* FCTC. The Gambia bans smoking in public transport * Countries that have not signed the treaty. vehicles and restricts smoking in government build- WHO = World Health Organization. ings, worksites, educational and health facilities. It does not, however, regulate taxation, advertising, DISCUSSION sponsorship and promotion of events by tobacco companies. The display of health warnings and cigarette Our review of published data on cigarette smoking in constituents on tobacco packets is not legally en- four countries in sub-Saharan Africa reveals a high forced. There is no legal prohibition of cigarette sales prevalence of smoking, especially among young peo- to minors. Uganda restricts smoking in government ple. There are no data on general populations and buildings and advertising in certain media and re- hence comparisons between the countries studied can quires that a health warning be prominently displayed only be made with caution. There is lack of a stan- on cigarette packs. However, these fall short of the dardised defi nition of ‘smoking’ among studies.19 FCTC recommendations (Table 3). Liberia restricts Most estimates of cigarette smoking/tobacco use prev- smoking in educational and health facilities. It does alence are outdated and may not refl ect current rates. not regulate the other provisions of the FCTC. Tobacco control measures are largely inadequate. The lack of published data for Liberia refl ects the scenario in most regions of sub-Saharan Africa. * http://www.who.int/tobacco/media/en/Liberia.pdf The prevalence of tobacco use varies by country 168 The International Journal of Tuberculosis and Lung Disease

Table 3 Tobacco control measures in Kenya, the Gambia, Uganda and Liberia

Tobacco control provision Kenya*† The Gambia† Uganda† Liberia† Increasing taxation Not specifi cally provided for in tobacco No data sources found Tobacco draft in No specifi c provision. above infl ation bill. Current taxes as follows: parliament. Current Taxation as follows: rate Excise tax, 160% taxation as follows: Customs user fee, Sales tax, 18% Excise tax, 130% 10% Import duty, 30% Sales tax, 17% Import duty, 24.5 Tobacco tax, 10% total tax revenue Import duty, 60% LCU/kg or 70% (12% COMESA CIF, whichever is countries) higher + 25% Tobacco tax, 9% total surcharge on tax revenue CIF value Banning advertising, Ban on advertising in print and Not regulated Restricted advertising in Unknown sponsorship, and electronic media, on cigarette sticks certain media promotion and packets. Ban on sponsorship of Sponsorship of events by sporting or other events by tobacco tobacco companies companies. Ban on endorsements, and promotions not cash rebates, participation in regulated lotteries, etc Banning or Ban of smoking in cinema halls, health Ban on smoking in Restricted in government Restricted in restricting institutions; restaurants, public buses, trains, taxis, buildings educational and smoking in public service vehicles, aircrafts, passenger ferries Smoking in other public health care facilities places ships, trains, education facilities, Restriction of smoking places and transport public buildings, public roads, in government not regulated railway lines, airports, oceans, buildings, worksites, beaches, lakes and water ways, educational facilities ports, piers, shores; public parks and and health care forests; sports and recreational centres facilities Requiring prominent All packets to bear the message Not regulated Required package health Not regulated health warnings ‘WARNING’ in the two national warning/message and messages on languages and in 17 point type, tobacco packages followed by the prescribed health message Requiring Requires that constituents of tar, Not regulated Not regulated Not regulated constituent labels nicotine and carbon monoxide be and addictive prominently displayed levels and testing methods Prohibiting sales and Age verifi cation at point of sale; ban Not regulated Not regulated Not regulated distribution of on sales in places to which minors tobacco products have access, ban on sponsorship of to and by minors school events

* Tobacco control bill 2004, available at www.kenyalaw.org/kenyalaw/klr_app/view_cap.php?CapID=621.21 † Africa region country proﬁ les available at http://www.who.int/tobacco/global_data/country_proﬁ les/en/index.html.4 COMESA = Common Market of Eastern and Southern Africa; LCU = local currency unit; CIF = cost / insurance/freight. and population studied. Of the four countries stud- lence of smoking to be much higher among rural than ied, Kenya has the highest prevalence, with three of urban students (21.9% vs. 5.3%). However, as Arua fi ve studies reporting rates of above 50% in diverse is a tobacco growing region, it may have a higher prev- populations: health care workers, primary school alence than the average rural area. Maasen et al. re- teachers, undergraduate students and out-patients. ported that 87.5% (116/133) of smokers in his study Health care workers and primary school teachers com- group (n = 282) were from rural areas. It is impor- prise important study groups, as these are often re- tant to identify areas of high prevalence, as these can garded as role models for tobacco prevention and be prioritised for tobacco control interventions. cessation. It is prudent to target health education at WHO estimates of prevalence of cigarette smoking these groups, which may be useful in educating the among general adult populations are as follows: UK larger public. Limited evidence suggests that smokers 26% (male 28%, female 24%),22 Russian Federation who perceive themselves to be in poor health may be 35.8% (61.3%, 15%),22 Germany 33.9% (37.1%, more likely to quit the habit.12 The study of hospital 30.5%),22 France 25.4% (30%, 21.2%),22 Australia out-patients is important in this regard. Walraven et 19.5% (21%, 18%),23 China 28.9% (53.4%, 4%),23 al. found smoking in both sexes to be more prevalent USA 17.6% (19.8%, 15.4%).24 Direct comparisons in rural areas than in urban areas. Among popula- with prevalence rates from our review sample cannot tions of rural (n = 1528) and urban (n = 2789) high be made owing to differences in populations studied school students, Mpabulungi et al. found the preva- and in defi nitions of smoking. Tobacco use and control in four African countries 169

GYTS Kenya (2001) reported a prevalence (cur- zaville, Congo: WHO/AFRO, 2008. http://www.afro.who.int/ rent use any tobacco product) of 13%,13 which is regionaldirector/speeches/rd20080531.html Accessed Decem- ber 2008. lower than the 16.6% reported by GTYS Uganda 4 Shafey O, Dolwick S, Gunidon G E, eds. Tobacco control coun- 16 (2006). Unpublished data from GYTS Kenya (2006) try profi les. 2nd ed. Atlanta, GA, USA: American Cancer Soci- (Department of Non-Communicable Disease, Minis- ety, 2003. http://www.who.int/tobacco/global_data/country_ try of Health, Kenya 2007) denote a higher preva- profi les/en/index.html Accessed November 2008. lence of 18.6%. Maassen et al. reported a high preva- 5 Patel P, Collin J, Gilmore A B. The law was actually drafted by us but the Government is to be congratulated on its wise ac- lence of cigarette smoking among young people in the tions. British American Tobacco and public policy in Kenya. Gambia of 47.2% (133/282 subjects). Estimates of Tobacco Control 2007; 16: e1. http://tobaccocontrol.bmj.com/ cigarette smoking among young people in Europe are cgi/content/full/16/1/e1 Accessed June 2008. as follows: UK 24.1%,22 Russia 22.5%,22 Germany 6 World Bank. 2006 World development indicators. Table 2.18. 33%22 and France 26.3%.22 In the Gambia, market- Washington DC, USA: World Bank, 2006. http://devdata.world bank.org/wdi2006/contents/Table2_18.htm Accessed June 2008. ing by tobacco companies, including offers of free 7 Chapman S, Yach D, Saloojee Y, Simpson D. All Africa confer- cigarettes, was a major contributor to the initiation of ence on tobacco control. BMJ 1994; 308: 189–191. young people to smoking. Interventions targeting the 8 Lore W, Lwenya R. Smoking habits in Kenya. II—a follow-up young provide an often-missed opportunity to at- study involving personnel working at Kenyatta National Hos- tack smoking early in the course of the epidemic. pital, Nairobi. East Afr Med J 1988; 65: 71–80. 9 Kwamanga D H, Odhiambo J A, Gicheha C. Tobacco con- The GYTS fi ndings are exceptional in that stan- sumption among primary school teachers in Nairobi. East Afr dardised methodology is applied, thus allowing for Med J 2001; 78: 119–123. direct comparison of prevalence data. The fi ndings of 10 Odek-Ogunde M, Pande-Leak D. Prevalence of substance use the survey are, however, not representative of the gen- among students in a Kenyan University: a preliminary report. eral population for whom tobacco control measures East Afr Med J 2001; 78: 119–123. 11 Othieno C J, Kathuku D M, Ndetei D M. Substance abuse in are relevant. out-patients attending rural and urban health centres in Kenya. Most studies included in the review address ciga- East Afr Med J 2000; 77: 592–595. rette smoking and not the use of tobacco in its other 12 Ortiz A, Martinez M, Torres A, Casal J, Rodriguez W, Nazario S. forms. These alternative forms of tobacco may be im- Predictors of smoking cessation success. P R Health Sci J 2003; 22: 173–177. portant in certain areas. Future research should quan- 13 Global Youth Tobacco Survey (GYTS). Report on the results of tify the real hazards posed by alternative forms of the Global Youth Tobacco Survey in Kenya—2001. Geneva, tobacco. Switzerland: WHO, 2002. www.cdc.gov/tobacco/global/GYTS/ Tobacco control measures are inadequate. Of the reports/afro/2001/kenya_report.htm Accessed June 2008. four countries, only Kenya has strong anti-tobacco 14 Walraven G E, Nyan O A, Van Der Sande M A, et al. Asthma, smoking and chronic cough in rural and urban adult communi- legislation in place (law enacted September 2007). ties in the Gambia. Clin Exp Allergy 2001; 31: 1679–1685. Uganda regulates some recommended provisions and 15 Maassen I T, Kremers S P, Mudde A N, Joof B M. Smoking is yet to pass its anti-tobacco bill into law. Most pro- initiation among Gambian adolescents: social cognitive infl u- visions are not regulated in Liberia and the Gambia. ences and the effect of cigarette sampling. Health Educ Res 2004; The strength of our review is the fact that four 19: 551–560. 16 Global Youth Tobacco Survey (GYTS). The Uganda Global countries in different geographical areas were included, Youth Tobacco Survey report (2008)—tobacco control policy thus providing a broad assessment of cigarette smok- implications. Geneva, Switzerland: WHO, 2008. http://www. ing in the sub-Saharan Africa region. who.int/entity/tobacco/surveillance/Uganda__Brazzaville08. pdf Accessed November 2008. 17 Mpabulungi L, Muula A S. Tobacco use among high school CONCLUSION students in a remote district of Arua, Uganda. Rural Remote Health 2006; 6: 609. Standardised surveys on the prevalence of tobacco use 18 Mpabulungi L, Muula A S. 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RÉSUMÉ

CADRE : La prévalence du tabagisme est en voie de pro- pays en utilisant les informations fournies par les départe- gression dans les pays en développement. Ces pays à ments de la santé correspondants. faibles ressources devront faire face aux maladies liées RÉSULTATS : On note une prévalence élevée du taba- au tabac avant d’avoir éliminé les maladies transmissi- gisme au Kenya, en Ouganda et en Gambie. Aucune bles courantes. donnée sur la prévalence du tabagisme n’est publiée MÉTHODES : Nous avons mené une recherche informa- pour le Libéria. Les mesures de lutte contre le tabagisme tisée sur PubMed pour identifi er les estimations de pré- sont inadaptées. valence du tabagisme publiées au Kenya, en Gambie, en CONCLUSION : Des études standardisées de prévalence Ouganda et au Libéria. Nous avons également fait la re- impliquant la population générale doivent être menées. vue des mesures de lutte anti-tabac dans chacun de ces Les efforts de lutte anti-tabac doivent être renforcés.

RESUMEN

MARCO DE REFERENCIA : La prevalencia del tabaquis- RESULTADOS : Se observó una alta prevalencia de taba- mo está aumentando en los países en desarrollo. Estos quismo en Kenia, Uganda y Gambia. No existen datos países con escasos recursos tendrán que afrontar enfer- publicados sobre la prevalencia de tabaquismo en Libe- medades causadas por el tabaquismo antes de haber ria. Las medidas de lucha contra el tabaquismo se con- eliminado las enfermedades contagiosas frecuentes. sideraron inadecuadas. MÉTODOS : Se llevó a cabo una búsqueda computarizada CONCLUSIÓN : Se precisan estudios estandarizados de en la base de datos PubMed con el fi n de determinar las prevalencia del tabaquismo, que cubran la población gene- estimaciones de prevalencia de tabaquismo publicadas ral. Es necesario fortalecer las medidas de lucha contra el en Kenia, Gambia, Uganda y Liberia. Se analizaron tabaquismo. además las medidas de lucha contra el tabaquismo en cada país, a partir de la información suministrada por los respectivos departamentos de salud.