Tomorrow’s regular customers? Stamping out tobacco use in the Middle East and Africa Supported by A report from the Economist Intelligence Unit Tomorrow’s regular customers? Stamping out tobacco use in the Middle East and Africa Preface omorrow’s regular customers? Stamping out tobacco use in the Middle East and Africa is a research Tpaper written by the Economist Intelligence Unit and sponsored by Pfizer. The author is Jason Sumner and the editor is Katherine Shields. Vanessa Barchfield also contributed to the report. The findings are based on more than 40 interviews with experts from government, academia, NGOs and the tobacco industry in the Middle East, Africa and elsewhere. We would like to thank the Economist Intelligence Unit’s extensive network of country analysts for organising and conducting most of these interviews. We would also like to thank our sponsors and the experts who participated in the interviews for their time and valuable insight. The views in this report are those of the authors, and do not necessarily represent the views of, and should not be attributed to, Pfizer. October 2009 © The Economist Intelligence Unit Limited 2009 Tomorrow’s regular customers? Stamping out tobacco use in the Middle East and Africa Introduction and key findings n much of the Western world, smoking is in retreat. After peaking in the post-second world war Iera, tobacco consumption has been in steady decline since the 1970s, halving in many countries as the evidence around nicotine’s detrimental health effects swelled. Over the decades, incremental tax hikes, advertising bans and public awareness campaigns—among other policies—have led to a seismic shift in public attitudes towards smoking. Governments, wary of the future burden that a next generation of smokers could add to the already mounting healthcare costs associated with retiring baby boomers and obesity-related illness, have been pushing forward ever-tighter tobacco controls, and more expansive public awareness and cessation programmes. Acceptance is growing. France has earned praise for a national ban on public smoking enacted in 2007 that has been both well accepted and well enforced, countering the romantic popular notion that cigarettes are as inseparable from French life as red wine and cafes. In the US, home to many of the Big Tobacco producers and where adult smoking rates have already fallen from 37% to 20% in the last 40 years, Congress recently gave broad powers to the government to regulate tobacco products, and will force cigarette makers to disclose ingredients and place prominent warnings on packaging, among other reforms. Yet in the developing world, governments are only starting to wake up to the tobacco problem. According to the World Health Organisation (WHO), the developing world’s share of total smokers climbed from just over 40% in 1970 to 70% by 2005. By 2030, the WHO forecasts that 80% of tobacco-related deaths will be in low- to middle-income countries. For developing-world countries that aim to emerge as major economic players, the future social and financial penalties of rampant tobacco consumption could be crippling. Preventable, early deaths first and foremost cause unnecessary suffering at an individual level. At a macroeconomic level, premature mortality among those who would otherwise be healthy saps national productivity. The Centers for Disease Control (CDC) in the US reckons that lives shortened by tobacco consumption cost the country US$97bn per year. The European Union calculates yearly productivity losses in Europe at between €69.8bn and €86bn. Soon—and in many countries the impact is already being felt—governments grappling with expanding welfare costs as their populations age will have to add the burden of treating smoking- 2 © The Economist Intelligence Unit Limited 2009 Tomorrow’s regular customers? Stamping out tobacco use in the Middle East and Africa related diseases such as cancer, heart disease and respiratory disease. Health ministers throughout the emerging world understand the risks, but progress on anti-smoking policies has been sluggish because of the addictive nature of nicotine and politicians’ understandable reluctance to turn their backs on the revenue and jobs provided by the tobacco industry. This report focuses on one portion of the developing world—the Middle East and Africa (MEA)— which has become a key battleground in the struggle over government policy and public attitudes. Although the region can lay claim to adult smoking rates mostly on par or lower than those of many Western and developing nations, expanding populations mean that even if rates were to stay relatively steady, the absolute numbers of smokers would still rise. The MEA region also poses other deeply entrenched challenges. These include rising youth smoking rates, particularly among girls, a prevailing culture of acceptance around tobacco, especially the water pipe, widespread governmental ambivalence and a strong tobacco industry lobby. But charities and other non-governmental organisations (NGOs) have gained a foothold in recent years. They often work on a shoestring, but are increasingly supported with much-needed financial lifelines from rich Western philanthropists. “There is a change in mentality in our region. Ministries of health are working with the WHO and other NGOs—bringing together all the people working on tobacco control,” says Dr Jean-Pierre Baptiste, a regional adviser with the WHO’s Tobacco Free Initiative in Algeria. He is one of more than 40 experts from government, academia, NGOs and the tobacco industry interviewed for this report. But are their efforts enough? In this paper, we investigate the progress that has been made, the challenges that remain, what lessons can be drawn from successful policies elsewhere and how the landscape could look in a decade or two. We examine ten major markets in-depth—four in North Africa: Egypt, Algeria, Morocco and Tunisia; two in Sub-Saharan Africa: Nigeria and South Africa; and four in the Middle East: Lebanon, Jordan, Saudi Arabia and the United Arab Emirates (UAE). The key findings of the report are highlighted below. Youth smoking rates look dangerously high…and are rising In most MEA countries, while smoking rates among adults appear generally to have held steady in the last ten years, youth rates are rising. In Lebanon, which has one of the worst youth smoking rates in the region, two-thirds of boys and more than one-half of girls between 13 and 15 years of age smoke some form of tobacco, at least double the rates for Lebanese men and women. Campaigners are duly worried because most lifelong smokers start before they turn the age of 18. In North Africa and the Middle East, the water pipe has become ubiquitous Seen as trendy and traditional, the water pipe has surged in popularity in the past decade, and this factor more than any other is believed to account for the rise in tobacco consumption among children. Variously known as hookah, nargile or shisha, the water pipe can deliver a hit many times more powerful than a cigarette, yet there is a widespread belief that it is less harmful than other types of tobacco. Some parents encourage their children to smoke the pipe and it is increasingly popular with young women, who smoke it in cafes in more liberal cultures and at home behind closed doors in more conservative countries. 3 © The Economist Intelligence Unit Limited 2009 Tomorrow’s regular customers? Stamping out tobacco use in the Middle East and Africa Governments rarely speak with one voice In general, anti-tobacco policies are weak and contradictory. Even countries that are seen as leaders in the region, such as Egypt, see infighting between ministers. Finance departments point to the revenue and jobs generated by the tobacco industry, while health ministers argue that the long-term costs of caring for tobacco-related illnesses far outweigh any short-term benefits. Bans are sometimes strict on paper, but rarely in practice Smoking restrictions vary throughout MEA, but with a few exceptions the laws are poorly enforced. Advertising bans have been more successful, with a handful of countries receiving good scores from the WHO for both the completeness of their laws and strict enforcement. Regional co-ordination is poor, however. Television ads are forbidden in Jordan, but its neighbour, Lebanon, has no restrictions, so Jordanian children are treated to a bevy of cigarette ads via Lebanese satellite. NGOs punch above their weight To the extent that governments have taken action, it is often due to the influence of NGOs. Dr Judith Longstaff Mackay, a senior adviser at the World Lung Foundation, a charity, says in the past ten years there has been a “professionalisation of tobacco control” in MEA. They focus on influencing governments and public attitudes with awareness campaigns, training and assistance for doctors, and lobbying for smoke-free zones, often one city at a time. In Nigeria, campaigners cheered when, in 2008, after much pressure, the capital city of Abuja was made a smoke-free zone. Better data are needed to support awareness campaigns, acceptance and enforcement Even on the most optimistic projections, a combination of prevalence trends and population growth means that in two decades there are likely to be several million more people smoking in MEA than there are today. Whether this depressing trajectory proves true will depend on the success or failure of anti- smoking campaigners and their allies in the health ministries. Yet success in the West in pushing down prevalence rates from the high 60% range to one-third of those rates today gives campaigners hope for MEA. With many efforts just getting off the ground, public awareness is beginning to grow. To keep up the pressure, anti-tobacco groups require consistent data on smoking rates and trends, and more hard evidence on the effects of the culturally acceptable water pipe.