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.
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 profits 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 field. 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.
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.
Kenya Tobacco Situational Analysis Consortium
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 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.
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.
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.
Since 1999, Mauritius has made signifi cant progress in tobacco control, and with new and improved legislation in 2008, Mauritius has emerged as one of the regional leaders in tobacco control. It has even emerged as a world leader in areas such as prohibiting corporate social responsibility (CSR) activities and compelling the inclusion of very large graphic warning labels on cigarette packages (65 percent of the package's largest sides). This progress has been important to address high prevalence rates which, though on the decrease generally, remain very high in some groups (the rate for adult male daily smokers as of 2009 remains greater than 32 percent).
There is clear support for tobacco control at the highest levels in the government. The Ministry of Health and the attorney general's office have been particular leaders. The tobacco control civil society movement, led by ViSa, is small but very active and a crucial watchdog of both the industry and the government's efforts to combat tobacco use. Currently, the tobacco control community is seeking to assess the successes and challenges of the recent legislative and regulatory changes, including the always demanding task of enforcement.
In general, the newest regulations are more than FCTC-compliant across most areas including advertising, sponsorship and promotion; labeling and packaging; and smoke-free places. Though not a part of the latest legislation, a tobacco-specific taxation strategy has a preliminary foothold and remains an area ripe for further development.
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.
Despite Zambia's sizeable tobacco cultivation and its signifi cant resource constraints (it is rated 165 of 177 countries on the Human Development Index), it is emerging as a tobacco control story with promise. It has signed and ratifi ed the Framework Convention on Tobacco Control (FCTC), and has existing, though decidedly problematic, laws and apparent will in several key sectors to take on new tobacco control challenges. Prevalence rates have been poorly measured for adults, but appear to be high relative to other Sub- Saharan African countries. By some accounts, 40 percent of male adults are smokers (though probably not daily smokers) while less than 10 percent of women are smokers. Youth smoking is lower at around 10 percent for daily smokers. Zambia also has a growing problem with noncigarette tobacco use.
By nearly all accounts, most of the existing legislation is vague and weak, and requires redevelopment. There is a movement in the advocacy community to seek these changes in the form of new legislation. This task, however, will require major efforts on the part of the advocacy community to educate (and seek to infl uence) policymakers using solid research. With a new government, there may be a genuine window of opportunity to pursue this avenue in the short term and many high-level policymakers have indicated overt support for tobacco control including the president, the vice president, the minister of agriculture and the mayor of Lusaka (the capital city).
This chapter explains the political mapping process that teams from the African Tobacco Situational Analyses (ATSA) initiative utilized to examine the political, economic and social contexts in which they were seeking to reform tobacco control policy. In brief, the process asks proponents of policy change to identify relevant domestic and international institutions and interests, and to consider how their roles and interactions help to shape policy in a particular country. The process is broadly framed by two theoretical constructs borrowed from the political science literature: both political institutions and interest groups influence policymaking and policy outcomes – independently and interactively. More specifically, it is the principal structural and organizational characteristics of the two entities, in addition to how they interact, that significantly shape policy. In other words, the individuals may change, but the types of actors and the institutional structures tend to be relatively static and deeply influence the making of policies and the outcomes generated by them. Understanding the fundamental nature of these central components can contribute markedly to successful navigation of the policy process.
Proponents of the so-called “new institutionalism” maintain that the actual structure of the political system will significantly condition outcomes. These structures include major features such as presidential versus parliamentary systems, unitary versus federal designs and the relative development and influence of the judicial branch, but also less obvious ones such as the autonomy and power of government ministries and the cabinet.
Burkina Faso has several tobacco control measures in place as the result of a set of regulations – the “Raabo” – promulgated by the executive branch in 1988, which includes basic provisions for smoke-free policies, advertising bans and warning labels. However, like many countries in Sub-Saharan Africa, the regulation is weak in terms of its basic parameters, implementation and enforcement. As a result, the tobacco control in recent years has been pursuing comprehensive, FCTC-compliant tobacco control legislation (the country ratified the treaty in 2006). In 2010, the Council of Ministers approved a draft bill that had received significant input from the tobacco control community, which was then passed on to the National Assembly for legislative approval. At the same time, however, another bill was introduced into the National Assembly that had significant input from the tobacco industry. The latter of the two bills was approved by the legislature.
Concomitantly, tobacco control advocates continue to pursue the enforcement of existing smoke-free legislation. Although Burkina Faso has traditionally been a highly centralized government, in the last few years the government has taken sizeable steps to decentralize. As a result, significant powers, particularly in the area of health, have been devolved to the 359 mayors of the main municipalities. The ATSA team has been working with a sample of 45 of these elected officials and their staff to educate them about tobacco issues and to encourage and help them enforce smoke-free policies. They hope that success in some or all of the 45 municipalities will be a catalyst for change across the country.
Despite the demonstrated efficacy of increased tobacco taxation as a primary deterrent to tobacco use, the vast majority of the countries participating in the Africa Tobacco Situational Analyses (ATSA) initiative do not yet employ taxation as a tobacco control strategy. Though all 12 ATSA countries levy taxes on tobacco products, only South Africa has been able to create, implement and enforce significant tobacco taxation aimed purposefully at reducing consumption. This chapter seeks to furnish a regional context of tobacco taxation in Africa and to analyze the challenges that countries face in attempting to utilize such policy instruments.
Tobacco taxation generates a distinct set of important policy dynamics that merit serious consideration, particularly for advocates seeking policy change. Proponents of tobacco tax policy reform – i.e. targeted tax increases – must take their well-researched, ironclad case for change to government in order to convince them of the tangible revenue and public health benefits. They also have to be prepared for vigorous opposition from the tobacco industry and/or their allies, which will inevitably present a doomsayer scenario of decreased tax revenue and job loss. On the side of actual policy provision, proponents within government must develop policies that will be effective over the long term, particularly instituting a codified system of substantial specific excise tax increases that will account effectively for changes in personal income and inflation. Proponents within the government must also be prepared for opposition from colleagues towards these reforms, based on concerns over their constituency support and/or ideological preferences (e.g. lower taxes).
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.
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