Chapter 12 Smokeless Tobacco Use in the African Region 353 Blank page. Smokeless Tobacco and Public Health: A Global Perspective Chapter Contents Description of the Region ........................................................................................................................357 Prevalence of Smokeless Tobacco Use....................................................................................................358 Types of Products and Patterns of Use ....................................................................................................362 Toxicity and Nicotine Profiles .................................................................................................................365 Health Problems Associated With Product Use.......................................................................................365 Marketing and Production Practices of Industry .....................................................................................367 Production ..........................................................................................................................................367 Distribution ........................................................................................................................................367 Marketing ...........................................................................................................................................368 Current Policy and Interventions .............................................................................................................369 Summary and Conclusions ......................................................................................................................370 References ................................................................................................................................................372 Tables, Figures, and Maps Table 12-1 Population and land area of selected countries in the African Region ............................357 Table 12-2 Percentage of adolescents aged 13–15 years who currently used smokeless tobacco in the African Region, from the Global Youth Tobacco Surveys, 2007–2009 ................359 Table 12-3 Percentage of adults who currently used smokeless tobacco in the African Region, 2003–2010........................................................................................................................360 Table 12-4 Toxicity and nicotine profiles of selected smokeless tobacco products used in the African Region .................................................................................................................365 Figure 12-1 Snuff products used in some African countries ...............................................................364 Figure 12-2 Snus information leaflets promoting situational use ........................................................369 Map 12-1 Prevalence of smokeless tobacco use among adults in the World Health Organization’s African Region ........................................................................................361 355 Blank page. Smokeless Tobacco and Public Health: A Global Perspective Description of the Region The African Region of the World Health Organization (WHO), as a geographic entity, refers to the area of the African continent that lies south of the Sahara, excluding the Sudan, South Sudan, and Somalia, but including Algeria and Mauritania. It covers a total area of about 30 million square kilo meters.1 The African Region consists of 46 countries2 divided into 5 subregions: Western, Eastern, Southern, Central, and Northern. The population of the African Region was estimated at 839 million in mid-2010,1 or 12.2% of the world’s population, with a 2.5% rate of natural increase.3 Table 12-1 displays land area and population information for 34 of these countries.4 Rural Africans have the lowest level of accessibility in the developing world: less than 40% of rural Africans live within two kilometers of an all-season road.5 Of the 46 countries in the region, 41 had ratified the WHO Framework Convention on Tobacco Control (FCTC) as of September 2013.6 The five countries that had not ratified the Convention as of 2012 are Malawi, Zimbabwe, Mozambique, Eritrea, and Ethiopia (Mozambique and Ethiopia have signed but not ratified). Malawi is one of the leading tobacco producers in the world, with an estimated yield of 208,105 metric tons in 20097; tobacco is grown on about 3% of Malawi’s total agricultural land.7 South Africa is the largest and arguably the most lucrative cigarette market in the WHO African Region. Multinational tobacco companies are involved in the manufacture of both cigarettes and smokeless tobacco (ST) products in South Africa. Table 12-1. Population and land area of selected countries in the African Region Country Area (km2) Population (thousands) Algeria 2,364,533 35,468 Benin 112,025 8,850 Botswana 669,000 2,007 Burkina Faso 274,483 16,469 Cameroon 478,024 19,599 Cape Verde 4,033 496 Central Africa 628,714 4,401 Chad 1,247,444 11,227 Congo 336,917 4,043 Côte d’Ivoire 323,574 19,738 Democratic Republic of Congo 2,357,000 65,966 Gambia 11,294 1,728 Ghana 239,137 24,392 Guinea 243,463 9,982 Kenya 578,757 40,513 Lesotho 30,153 2,171 Liberia 110,944 3,994 Madagascar 591,829 20,714 357 12. Smokeless Tobacco Use in the African Region Smokeless Tobacco Products Country Area (km2) Population (thousands) Malawi 118,262 14,901 Mali 128,083 15,370 Mauritania 1,153,333 3,460 Namibia 761,000 2,283 Nigeria 926,450 158,423 Rwanda 26,362 10,624 Sao Tome and Principe 959,302 165 Seychelles 458 87 Sierra Leone 7,156 5,868 South Africa 1,222,756 50,133 Swaziland 17,441 1,186 Tanzania (United Republic of) 954,064 44,841 Togo 56,868 6,028 Uganda 240,468 33,425 Zambia 769,941 13,089 Zimbabwe 392,844 12,571 Total 18,336,112 664,212 Abbreviation: km = kilometer. Source: United Nations 2011 (4). Prevalence of Smokeless Tobacco Use Use of ST products is common in some countries of the African Region, and various forms of products are used. Little information is available on prevalence of use in the region, and the data that are available tend to be dated and/or limited to small areas or subregions. Tables 12-2 and 12-3 present the prevalence data for each African Region country for which data are available, by the types of products used and the age of users, and Map 12-1 illustrates the available adult prevalence rates by country. Caution should be exercised when comparing the estimates from different surveys, because of the differences in sampling, questions asked, and definitions. The definition of current use varies. For example, some surveys define current use as any use within the past 30 days, but other surveys ask about different time periods; some surveys ask about daily use and use on some days, and still other surveys ask about “current” use without defining the term further. The prevalence of ST use varies across countries and across geographic areas within countries. For example, national prevalence rates for adults in Nigeria are relatively low (Table 12-3), but higher rates have been found in a state in the northeastern geopolitical zone of Nigeria among people aged 15 and older (10.8% for males and 4.1% for females).8 358 Smokeless Tobacco and Public Health: A Global Perspective Table 12-2. Percentage of adolescents aged 13–15 years who currently used smokeless tobacco in the African Region, from the Global Youth Tobacco Surveys, 2007–2009 Country Year Total (%) Boys (%) Girls (%) Botswana 2008 11.3 11.3 11.4 Burkina Faso – Bobo Dioulasso 2009 13.2 12.1 14.0 Burkina Faso – Ouagadougou 2009 10.2 11.2 9.2 Cameroon – Yaounde 2008 5.1 5.4 4.4 Cameroon – outside Yaounde 2008 10.9 12.0 9.4 Central African Republic – Bangui 2008 15.4 21.9 8.0 Congo 2009 16.4 18.3 14.1 Côte d’Ivoire 2009 5.6 6.2 4.9 Democratic Republic of Congo – Kinshasa 2008 20.8 20.6 20.1 Democratic Republic of Congo – Lubumbashi 2008 17.8 18.3 16.4 Gambia – Banjul 2008 21.9 20.1 23.3 Lesotho 2008 14.4 14.7 13.6 Liberia – Monrovia 2008 8.3 9.0 6.6 Madagascar 2008 5.7 6.2 5.4 Malawi – Lilongwe 2009 11.0 10.3 11.7 Malawi – rest of country 2009 8.9 11.3 6.7 Namibia 2008 16.0 15.6 15.8 Rwanda 2008 7.4 8.3 6.0 Seychelles 2007 5.5 5.2 5.4 Sierra Leone – West urban 2008 17.3 13.6 18.8 Sierra Leone – West rural 2008 22.7 18.9 24.5 Swaziland 2009 5.4 6.0 5.0 Tanzania – Arusha 2008 6.2 6.9 5.5 Tanzania – Dar es Salaam 2008 4.6 4.6 4.3 Tanzania – Kilimanjaro 2008 5.7 5.6 5.7 Togo 2007 6.2 6.9 4.8 Uganda 2007 9.4 8.6 9.6 Zambia – Lusaka 2007 15.6 0.9 15.4 Zambia – Kafue 2007 16.7 17.0 16.5 Zambia – Chongwe and Luangwa 2007 14.1 15.3 13.2 Zimbabwe – Bulawayo 2008 5.4 7.5 3.5 Zimbabwe – Harare 2008 5.7 6.4 5.0 Zimbabwe – Manicarland 2008 7.6 8.3 6.3 Source: Global Youth Tobacco Surveys, 2007–2009 (50). 359 12. Smokeless Tobacco Use in the African Region Smokeless Tobacco Products Table 12-3. Percentage of adults who currently used smokeless tobacco in the African Region, 2003–2010 Country Year Age Group (Years) Total (%) Men (%) Women (%) Algeria* 2010 15+ 5.7 10.4 0.8 Benin† 2008 25–64 9.2 12.7 5.7 Cape Verde* 2007 25–64 4.6 3.5 5.8 Chad (subnational)* 2008 25–64 1.2 1.9 0.4 Ethiopia‡ 2005 Men, 15–59; Women, 15–49 — 3.0 0.6 Gambia† 2010 25–64 1.1 0.8 1.4 Ghana‡ 2008 Men, 15–59; Women, 15–49 — 0.9 0.2 Guinea (subnational)† 2009 15–64 1.4 1.4 1.5 Kenya‡ 2008–2009 Men, 15–54; Women, 15–49 — 1.8 1.3 Lesotho‡ 2009 Men, 15–54; Women, 15–49 — 1.3 9.1 Liberia‡ 2007 15–49 — 2.3 2.4 Madagascar‡ 2008–2009 Men, 15–59; Women, 15–49 — 22.6 19.6 Malawi† 2009 25–64 3.5 1.9 5.0 Mali (subnational)† 2007 15–64 2.7 5.0 1.2 Mauritania† 2006 15–64 9.0 5.7 28.3 Namibia‡ 2006–2007 15–49 — 1.8 2.3 Nigeria‡ 2008 Men, 15–59; Women, 15–49 — 3.2 0.5 Sao Tome and Principe† 2009 25–64 2.8 3.8 1.9 Sierra Leone‡ 2008 Men, 15–59; Women, 15–49 — 1.3 4.7 South Africa* 2003 15+ — 2.4 10.9 Swaziland† 2007 25–64 1.6 2.6 0.8 Uganda‡ 2006 Men, 15–54; Women, 15–49 — 3.9 2.6 Zambia‡ 2007 Men, 15–59; Women, 15–49 — 0.2 1.2 Zimbabwe‡ 2005–2006 Men, 15–54; Women, 15–49 — 1.9 0.5 *Individual country surveys from: WHO Report on the Global Tobacco Epidemic, 2011 (51).