Major obstacles to tobacco harm reduction exist in high-income, “western” countries from the United States to Australia. Yet it’s vital to remember that of the world’s 1.1 billion smokers, who suffer 7 million annual smoking-related deaths, around 80 percent live in low- or middle-income countries where challenges are very different.
To take one key continent, Africa has some of the highest smoking rates in the world. “We have 77 million smokers, the majority of which come from the lower-income population,” Joseph Magero, who heads Africa’s continent-wide Campaign for Safer Alternatives, told Filter. “Keeping these people alive and preventing irreparable damage should be regarded as the most urgent priority.”
Cigarette consumption rose by 52 percent in sub-Saharan Africa between 1980 and 2016, and the region’s fast-growing population means smokers’ numbers are set to swell further—underlining the urgency of Magero’s point.
To illustrate some of the challenges faced by African populations—and the need for country-specific approaches—I’ll focus here on two examples. In two East African nations, Kenya and Malawi, experts and advocates are fighting in their own ways to reduce smoking-related disease and death.
Malawi is a small country in southeast Africa with a population of 18 million, still relatively young having obtained independence from the United Kingdom in 1964. Malawi’s population is overwhelmingly rural, its economy primarily agricultural.
Raw tobacco dominates Malawi’s export markets; according to the United Nations Food and Agriculture Organization, 81 percent of Malawi’s foreign exchange earnings came from tobacco farming. This creates a unique context for smoke-free and tobacco harm reduction initiatives.
According to data collected by the Foundation for a Smoke-Free World,* Malawi’s population has seen declines in smoking while not being a party to the World Health Organization’s Framework Convention for Tobacco Control treaty.
Given this, the regulatory environment for smoking in Malawi is very permissive. There are no advertising rules, no public smoking bans, no age restrictions for purchases, and minimal rules governing health warning disclosure.
Tobacco Atlas, a project of the American Cancer Society and Vital Strategies, additionally reports survey data that 16.7 percent of Malawian men aged 15 and older smoke—a figure that’s above average for men in low-income countries. The rate for women aged 15 and older is just 3 percent.
Other datasets suggest that smoking rates for men and women have declined from 25.5 percent and 6.1 percent, respectively, in 2003 to 18 percent and 1.2 percent in 2010. That’s well over 1 million smokers.
Local experts say that Malawians still have little exposure to knowledge of safer nicotine products like vapes or oral tobacco.
“In low and medium-income countries like Malawi, there is a need for economically feasible and culturally acceptable safer nicotine products,” Chimwemwe Ngoma, a harm reductionist and social worker in Malawi, told Filter.
Ngoma, along with several other local volunteer tobacco harm reductionists, formed the nonprofit educational campaign THR Malawi in 2018. Its goal is to inform Malawians about both the health consequences of smoking and safer alternatives, promoting informed public and personal health decisions.
The answer, say Malawian harm reductionists, isn’t vapes.
However, “Information should be complemented by the availability of affordable, safer nicotine products,” Ngoma said. “Electronic cigarettes are not feasible for people living in rural Malawi where there is no readily-available electricity to recharge the devices. On top of that, E-cigs are expensive for an average smoker in Malawi. Products available [typically] cost about $90 [initial outlay] and are commonly used by the economically privileged individuals in urban areas.”
Ngoma emphasized how financially prohibitive vaping products are to many in his country. World Bank data shows that the average annual income in Malawi is $360. That means an average Malawian makes less than a dollar a day, with many in rural areas making far less. Tobacco, so plentifully grown in the country, is cheap and widely available.
So how can Malawi’s smokers access safer options that are also affordable? The answer to that question, say Malawian harm reductionists, isn’t vapes.
Instead, snus, a form of non-combusted oral tobacco, “can be more preferred as it is of low cost and can be home-made,” Wildred Jekete, a harm reductionist and social worker in Malawi, told Filter. “However, [snus] has to be of cheaper or of almost equal price to a pack of cigarettes to easily get the risk-reduced nicotine products in the hands of smokers.”
Research suggests that snus is much safer than smoking, with data showing that snus use cuts risk by 95 percent, similarly to vaping. Widespread uptake of snus among smokers in Sweden, for example, has dramatically reduced lung cancer rates.
Sahan Lungu, a marketing and communications specialist with THR Malawi, agrees that snus should be adopted as a part of a much larger agricultural transformation.
“Going into it, you should be aware beforehand that risk-reduced nicotine products such as e-cigs or heat-not-burn products are an expensive option for most of the smoking population in countries like Malawi, and currently we do not have a powerful force of demand that can scale up supply large enough to affect the price or affordability of purchase, running and maintenance of such products,” Lungu told Filter. “Such an intervention would be more effective among the more affluent members of society.”
“For the underprivileged smokers,” he continued, “your safest bet would be something along the lines of snus. The advantage with Malawi, in this case, is that it already grows a lot of tobacco, which is the main ingredient in making snus.”
Widespread dissemination of information about snus and other risk-reduced products is vital if such a transformation is to take place—which is where groups like THR Malawi come in.
To facilitate rapid change, such information will be aimed not only at consumers, but at policymakers and tobacco growers—encouraging the processing of more of Malawi’s tobacco into snus-type products.
Kenya, a country of 52.6 million that won independence from the UK in 1963, is one of the central economic hubs in East Africa. It faces smoking issues that are in some ways similar to those in Malawi but in others different.
Tobacco Atlas reports that 14.9 percent of Kenyan men aged 15 and older smoke combustible cigarettes, while just 1 percent of women do. Although Kenya’s surging population is heavily stacked toward children and younger people, that’s at least 3 million smokers. Again, data show decreases in smoking rates—but the declines are projected to level off, with many Kenyans still unable or unwilling to quit. Kenya is also a major producer and exporter of raw tobacco.
However, with a more industrialized economy and higher rates of average income compared with Malawi (the World Bank classifies Kenya as lower-middle income), a variety of tobacco harm reduction strategies are viable.
Smoking is dominant in urban areas, while smokeless tobacco is dominant in rural areas, meaning urban populations are the greatest focus of concern.
According to a 2018 analysis of data from the World Health Organization’s 2015 STEPS survey, cigarette use is high in slum areas of Nairobi, Kenya’s capital, as well as other areas of that city and other urban centers.
Rates of overall tobacco use are almost identical in urban and rural areas, according to this data (21.5 percent and 21 percent respectively). However, smoking is the dominant form of use in urban areas, while smokeless tobacco use is dominant in rural areas, meaning urban populations are the greatest focus of concern. Of almost 4,500 respondents in the analysis, just seven individuals, mostly young, urban and educated, reported vaping.
To some Kenyan tobacco harm reductionists—as in Malawi—information is the greatest health tool.
Chris Abuor, a human rights activist who founded VOCAL Kenya (Voices of Community Activists and Leaders) in 2018 in an effort to reduce the harms associated with drugs and bad policies, is embarking on a mission to disseminate nicotine health information through social media.
“Many people don’t have time to read a lot of stuff,” he told Filter, “and for that reason, it’s more appetizing and enticing to use creative images and catchy slangs to get their attention.”
In addition to online efforts, his group deploys the medium of Community Participatory Educational Theater in public schools—aimed at parents and teachers as well as children—in order to “use cultural narrative to mobilize, organize and educate, moving from known to unknown.”
Raising literacy levels and reducing poverty are part of this mission, but, said Abuor, “This might not even be about literacy as such, but innovation to find the best strategy to deliver a message in a more … acceptable way.”
A remaining challenge, according to Abuor, is ensuring that messaging about risk-reduced nicotine products, like vapes, is not construed by the public as tobacco-industry propaganda. He emphasized the importance of “the political question of industry and whose products these are, and not being perceived as pushing the industry agenda.”
“Introduction of e-cigarettes for existing smokers would be helpful since it is less hazardous,” he said, although, “we must consider accessibility and affordability of the products.”
Joseph Magero (photo via Twitter)
Joseph Magero of the Campaign for Safer Alternatives (CASA), who is also Kenyan, previously worked in the tobacco control field but became convinced of the need for harm reduction, rather than “quit or die” strategies, in his homeland. CASA was founded earlier this year to promote harm reduction in a transnational effort to cut smoking rates across Africa.
Magero’s vision for Kenya includes a market transition from combustibles to a full range of safer alternatives. He has long critiqued the highly controversial tobacco industry, including African market leader British American Tobacco,* for failing to promote safer products. BAT’s recent decision to open a snus plant in Kenya might herald better access. But better information is still essential: While Kenya has no laws prohibiting snus or vapes, experts say there is very little public awareness about the relative risks of different options.
“People who smoke do not forfeit their human rights, including the right to the highest attainable standard of health.”
The mission of CASA now extends across a continent that has long been abused by greed and corruption—with culprits ranging from tobacco companies to abusive governments and overseas interests—and requires, according to Magero, large-scale innovative thinking.
One of the critical roles of CASA is to communicate a nuanced, comprehensive and accurate “full message” about nicotine, alternative products, and cigarettes to empower Africans to take control of their health.
“People who smoke do not forfeit their human rights, including the right to the highest attainable standard of health,” Magero said. “Harm reduction opposes the deliberate hurts and harms inflicted on people who smoke cigarettes in the name of tobacco control and drug prevention, and promotes responses to nicotine addiction that respect and protect fundamental human rights.”
*Disclosures: The Influence Foundation, the nonprofit organization that operates Filter, has received grants from the Foundation for a Smoke-Free World and from Reynolds American, Inc, a subsidiary of BAT.
The author is a recipient of a 2019 Tobacco Harm Reduction Scholarship, administered by Knowledge-Action-Change (KAC) Communications and made possible by a grant from the Foundation for a Smoke-Free World. The people interviewed for this article and their organizations have also received KAC scholarships, although much of their past and current work is voluntary. KAC has also previously funded The Influence Foundation through a scholarship.
No funders have involvement in the planning or creation of Filter articles, per our Editorial Independence Policy.