Executive Summary

Despite considerable international activity in tobacco control, including shaping the Framework Convention on Tobacco Control (FCTC), comprehensive national legislation has been a struggle to achieve in Ghana. Accordingly, the most recent tobacco control efforts in Ghana, including the African Tobacco Situation Analysis (ATSA) initiative, have focused on advocating for national comprehensive legislation. Unfortunately, the legislation has been stalled for more than fi ve years. It is not clear how much support there is for the legislation in either the new cabinet or the national legislature. High-level changes in the health ministry have complicated these efforts, so the advocacy community has been once again regrouping to assess the potential for high-level support. In the interim, the tobacco control community has identifi ed other goals that may be more feasible in the short term. With comparatively low prevalence rates (approximately 5 percent) and a public generally compliant with informal tobacco control norms – particularly smoke-free public places of various sorts (e.g. hospitals, educational institutions, public transport, etc.) – a formalization of existing rules and regulations with an emphasis on enforcement could be sought concurrent to the pursuit of the broader legislation.

The Research and Development Division (RDD, formerly the Health Research Unit of the Ghana Health Service (GHS)) has been the principal leader of the ATSA team. While this unit is well-poised to conduct health research (it has strong ties to the Universities of Ghana and Nottingham) and public education, it has limitations, as an offi cial government entity, in advocating effectively for policy change.

Nigeria Tobacco Situational Analysis Coalition and Jeffrey Drope

Executive Summary

Nigeria is at a major crossroads in tobacco control, as comprehensive legislation was only passed by the National Senate in early 2011. The legislation is compliant with the Framework Convention on Tobacco Control (FCTC) and has been vetted by the domestic tobacco control community and its many international allies (e.g. Tobacco Free Kids (TFK), Framework Convention Alliance, International Development Research Centre (IDRC), etc.). With adult prevalence rates approaching at least 20 percent and increasing (and likely higher amongst youths), there is a clear need to address tobacco issues in the near term, especially in such a populous (> 150 million), varied (hundreds of distinct ethnic and/or linguistic groups) and poor country.

There appears to be considerable political support for the legislation at many high official levels, but Nigerian politics are very complex. Even before final presidential assent, the tobacco control community is shifting to consider the challenges of implementation and enforcement.

While seeking passage of national legislation, tobacco control proponents pursued other avenues. In November 2009, the tobacco control community team enjoyed a signifi cant victory when Osun State passed a comprehensive smoke-free law (one of the African Tobacco Situation Analysis (ATSA) initiatives). The team had been sensitizing state legislators and the statelevel executive branch (the governor and his staff) about tobacco control for months through education programs. The team has since shifted its efforts to enforcement.

Introduction

This chapter is dedicated to an outline of the Bravio or barrel race of Montepulciano, followed by analysis, which also targets some of the main themes gathered in the previous two chapters. The chapter opens with a presentation of the overall festival, a 1974 revival and modification of a competitive event from medieval times still marked by growth and innovation. Though similar to the Palio in being based on competition between contrade, it is far more fluid and less integrated into the civic fabric. The main features of the race (modified from a 1337 horse race), the ceremonial aspects of events preceding it, the evolution of costumes and the composition of the pageant – whose processing precedes all events – are outlined before a brief comparative analysis of the differences in the handling of ceremonial candle offerings in Siena and Montepulciano is given. The chapter then moves from the ceremonial aspects to the more hybrid, ‘carnivalesque’ entertainments found in the Bravio, but absent from the Palio. This is traced back to a part of the 1300s custom of holding a large fair on the occasion of the feast of the beheading of St John the Baptist, whose institution had preceded that of the horse race. Another aspect of the activities that surround the Bravio, namely the contrade fundraising dinners, is then compared to similar practice associated to the Palio in Siena.

Attempting to sum up the expansive work to change public health policy across 12 countries is a daunting but invigorating task. Arguably, the best avenue to a meaningful summary and fi nal analysis is to reexamine and synthesize some of the themes that emerge from the preceding chapters, including several that might be less obvious to the casual reader. We, the authors and editor, have sought purposefully to be mindful of drawing too much inference from this research. This decision is a result of our dissatisfaction with earlier work that claims too much causality when the evidence is simply not strong enough or offers explanations that are too facile. While duly acknowledging these concerns, we believe that we have examined the roles of and relationships among key actors and institutions involved in tobacco control policy in Africa in ways that are both rigorous and generalizable, and moreover, useful to both practitioners and researchers in the health and social sciences.

As was cautioned in Chapters 1 and 2, there is no unifi ed theory of public health policy generally or tobacco control policy specifi cally; improving tobacco control policy in such disparate political and economic contexts does not have a one-size-fi ts-all explanation or prescription. Fortunately, however, many useful patterns emerge from this collection that should help us to understand better these processes in developing countries both abstractly and systematically.

According to the FCTC “Guidelines for the Implementation of Article 11,” well-designed health warnings and messages are an important part of a range of effective measures to communicate health risks and to reduce tobacco use. Research evidence demonstrates that the effectiveness of health warnings and messages increases with their prominence. In comparison with small, text-only health warnings, larger warnings with pictures are more likely to be noticed, better communicate health risks, provoke a greater emotional response and increase the motivation of tobacco users to quit or to decrease their tobacco consumption. Larger picture warnings are also more likely to retain their effectiveness over time and are particularly effective in communicating health effects to low-literacy populations, children and young people. Other elements that enhance effectiveness include locating health warnings and messages at the top of the principal display areas; the use of color rather than just black and white; requiring that multiple health warnings rotate and appear concurrently; and periodic revision of health warnings and messages.

One of the particularly compelling possibilities with packaging and labeling restrictions is that it is not always necessary to address this issue using national legislation, though it certainly can be – and has been – done this way. In countries that are struggling with the passing of new legislation, this less burdensome option offers many possibilities. In fact, as this chapter demonstrates, many countries allow regulatory agencies, often but not always in health ministries, to handle many and even most issues regarding packaging and labeling.

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 defiant.

Introduction

This chapter is concerned with a particular methodology, based on an ontological view of reality, which was briefly introduced in Chapter 1. The aim is therefore to give more depth to what was briefly outlined earlier and frame this in terms of a psychosocial approach to research. Given the acknowledgement of issues of fluid connectivity as present and constitutive of reality as an ontological starting point for research, the aim is to outline how they can be accessed and what this says about learning as a process. In order to balance the highly abstract nature of the concepts to be outlined, examples of how these issues were reflected in the practice of research are given. Thus the chapter begins with an account of experiences in the initial phases of research and then jumps forward in time to offer reflections on the process of writing this chapter. This proved hard to give a final form to, given the complexity of material and its dynamic unbounded quality. The image of an unusual sculpture project is offered as a metaphor for this research, which may balance the inevitable reduction implied by the representational medium of words to which the book is by necessity wedded.

Executive Summary

Though the prevalence of daily smokers is comparatively low in Cameroon at 4 percent, the prevalence of occasional smokers (∼ 18 percent) and young smokers (∼ 14 percent) is higher and increasing across most social groups. There are already a number of tobacco control measures in Cameroon, including some limited smoke-free provisions, an advertising ban and some labeling requirements, but improved implementation and enforcement and a comprehensive national tobacco control bill remain central goals of the tobacco control community. Though Cameroon has ratified the Framework Convention on Tobacco Control (FCTC), none of the existing measures are FCTC-compliant.

There is evidence of support for tobacco control at the level of the president and at the ministerial level. The establishment of a Group of Experts on Tobacco Use (2007) by the national government is evidence of government interest and support. This group is charged with developing new legislation. Civil society action on tobacco control is still nascent in Cameroon.

Through 2010, the African Tobacco Situation Analysis (ATSA) team has been working to promote smoke-free policies in the Mfoundi Department (which includes Yaoundé) in the hope that this pilot phase will serve as a model that can be replicated at the national level. Major priorities for the tobacco control community include fine tuning the existing regulations, generating new and improved tobacco control legislation (either comprehensive legislation or piecemeal by area) and developing strategies to implement and enforce these new rules.

Introduction

Having had a rather long theoretical excursion into festival territory, it may be time to consider Montepulciano itself a little more closely before moving to consider other festivals and ideas. The placement of this short chapter and the delayed introduction to Montepulciano has been deliberate. The intention is to build a bridge between the previously examined Bruscello theatre and the Bravio or barrel race, presented in the following chapter, by better introducing the town and some of the themes in its history that have transpired as being relevant to both events, as well as to mirror and reflect on the town's pivotal position as a frontier town in both spatial and temporal terms. The mythic origins of Montepulciano, the persistence of fluid versions of the myth (already encountered in Bruscello plays) and the persistence of different aspects of the past in the physical fabric of the town are given some attention before looking back in history from earliest available records. This perspective highlights how Siena's threat to Montepulciano's independent development was kept at bay through becoming a frontier ally with Florence. There is then an interpretation of aspects already outlined, linking them to Deleuze's concept of the ‘Problem/Idea’ and anticipating some themes for further scrutiny. The proliferation of voluntary associations that appears as a particularly strong social tendency is another indication of the fluidity characterising the town, while the existence of another major avant-garde arts festival event that cannot form part of present analysis, but whose presence is significant, is acknowledged.

Executive Summary

The country's tobacco control success stands in sharp contrast to many other middle- and low-income countries where the tobacco epidemic is still growing. Large reductions in tobacco use have occurred in South Africa because of a combination of government commitment to comprehensive legislation and enforcement (four major pieces of legislation since 1992) and effective civil society–driven public health activism and community support. Moreover, research played an essential role by supporting both policy development and advocacy efforts. However, prevalence rates remain high (approximately 23 percent of adults are daily smokers; and noncigarette tobacco use, particularly in lower socioeconomic groups, is a continuing concern), the tobacco industry is powerful and the tobacco control community reports having to counter both public and government sentiment that tobacco control has “been done.” By the tobacco control community's own admission, for every victory, the industry has tried to claw back part of the gain – they believe not only that there is more work to be done, but that it will require continued vigorous effort.

Most recently, the tobacco control community won a signifi cant victory in ensuring that the 2010 FIFA World Cup would have smoke-free spectator venues. Currently, tobacco control advocates are examining the effi cacy of existing tobacco taxation policies. While South Africa previously had excellent tobaccooriented tax policies that directly decreased the affordability of cigarettes, recent falls in infl ation and economic growth have made these policies less effective.

Kenya Tobacco Situational Analysis Consortium

Executive Summary

Kenya is at a very exciting – perhaps even crucial – stage for tobacco control. In 2007, the national legislature passed a comprehensive bill that has urgently required dynamic and systematic follow-up in terms of implementation and enforcement in all major areas (e.g. smoke-free policies, labeling, advertising, etc.). The highly active Kenyan tobacco control community is well aware of these challenges and has begun to take proactive steps to address them, including the training of inspectors to enforce both smoke-free policies and bans on advertising, promotion and sponsorship. Notably, the training is a combined effort of the Ministry of Health (MoH) and civil society organizations, with some funding from external donors. Graphic warning labels and tobacco taxation strategies are also on the list of activities for short-term pursuit by these actors.

Though the political situation in Kenya is fraught with violent unrest following the 2007 national election and a wholesale reorganization of government, the tobacco control community is actively navigating the new landscape and maintaining close working relationships with policymakers and permanent ministry offi cials (i.e. nonelected and nonappointed). There is some continuity in personnel at the ministry level, which allows for greater consistency in activities and efforts. But there is an essential need for the community to stay well connected to the government because the tobacco industry (both British American Tobacco (BAT) and Mastermind) uses Kenya as a subregional hub for its operations, and these fi rms are aggressive in both their subversive marketing and their efforts to affect the policy process.

The harmful effects of tobacco use pose an imminent threat to the health of African people. As the tobacco epidemic shows signs of waning in some northern countries, a combination of factors such as low prevalence rates, young and burgeoning populations, growing disposable incomes and aggressive and unscrupulous advertising by multinational tobacco companies threatens to create a massive tobacco-related burden of disease in Africa, which will unfortunately add to existing public health challenges. The World Health Organization (WHO) reports that tobacco kills approximately 5.4 million people annually, which is more than HIV/AIDS, malaria or tuberculosis. More than half of these tobacco-related deaths are now in developing countries. Fortunately, in recent years, proponents of tobacco control have increased their efforts in Africa and there is now some notable progress in policy reform. However, a great deal of work remains. Moreover, more country-specific or locally relevant research in Africa and across developing countries is necessary to complement these nascent efforts. While the research must be theoretical and empirical, it must also be highly relevant, accessible and useable by advocates of policy change.

Accordingly, the principal focus of this research is to examine the political, economic and social determinants of policy change in the area of public health generally and tobacco control more specifically. The research in the book is based on the 2008–10 African Tobacco Situational Analyses (ATSA) initiative, which was spearheaded by the International Development Research Centre's (IDRC) Research for International Tobacco Control (RITC) with funds from the Bill and Melinda Gates Foundation.

Research indicates that comprehensive bans on tobacco advertising, promotion and sponsorship (APS) are effective in reducing tobacco consumption. Across the 12 African Tobacco Situational Analysis (ATSA) countries, there is considerable variation in terms of the countries' progress in instituting such restrictions. Several countries, including South Africa and Mauritius, have strong provisions in place, while some countries, such as Senegal and Ghana, have much weaker provisions. In most countries, there is a need for stronger legislation and/or regulation to create bans or to improve existing ones. In all countries, there is a significant need to improve efforts at enforcement, particularly considering the tobacco industry's ongoing efforts to subvert the bans.

This chapter has several broad goals. First, it lays out the Framework Convention on Tobacco Control (FCTC) interpretation of these bans so that the reader can understand the legal basis for the strategy. Second, it discusses the status of and variation in the bans in the 12 ATSA countries by meaningfully grouping countries together by performance and/or common challenges. Finally, it raises some of the most pressing issues facing this tobacco control strategy that require further research, discussion and/or resolution.

FCTC Definitions and Article 13

Building on research findings that advertising, promotion and sponsorship bans are effective tobacco control strategies, a comprehensive strategy has been enshrined in Article 13 of the World Health Organization's (WHO) FCTC to provide broad guidelines for country-level implementation and enforcement.