Tobacco has long played a significant role in the culture of Rwanda—gifted and shared, and traditionally used at weddings, though this has now reportedly declined.
Rwanda’s smoking rate has fallen, from an estimated 15 percent of the adult population in 2000 to 10 percent in 2015. Changing societal attitudes and growing awareness of the risks of smoking are behind this.
The decline seems to be slowing, however, with only a slight further fall—to 9 percent—projected by 2025. The small, central African country still suffers over 2,000 smoking-related deaths each year.
Widespread adoption of harm reduction would accelerate smoking cessation. To achieve this, educating health care providers will be an important part of the puzzle, as my recent research reflects.
Who is smoking? The picture is incomplete, but past research on Rwandans aged 15-34 found higher rates among men and people with lower education levels, as in other countries. People with incomes smoked at higher rates, probably simply because they could afford to do so.
We also cannot discount potential impacts of lingering trauma from Rwanda’s 1994 genocide on some people’s tobacco use—particularly among older citzens, but also even for people born after those events. Trauma and PTSD are linked to higher smoking rates.
I distributed a survey among Rwandan medical students. Encouragingly, a majority had heard of tobacco harm reduction.
Tobacco harm reduction is not yet widely available here. As far as laws go, there are none specifically regarding nicotine vapes, though regulations do prohibit advertising of heated tobacco products or nicotine replacement therapy (NRT).
Nicotine pouches or snus could be important options in a country where around a quarter of households don’t have access to electricity. Nicotine vapes could also help many. Whatever the product, accessible pricing is essential.
Impacts will be minimized, however, if there is little public awareness of safer nicotine alternatives. And this is where health care providers could play a critical role—by getting the word out to people who smoke, and using their credibility to promote informed choices.
But if they’re to do that, these providers will need to be better informed themselves.
For my study, which has not yet been published, I distributed a survey among medical students at the University of Rwanda and the University of Global Health Equity, Rwanda, two institutions located in the capital of Kigali.
Encouragingly, a majority (58 percent) of the 263 students who responded had heard of the concept of “tobacco harm reduction,” signaling growing awareness of alternatives to traditional cessation.
Under 17 percent identified nicotine vapes as a cessation tool, and only 27 percent knew that vaping is less harmful than smoking.
However, most of these medical leaders of Rwanda’s future had not been educated about specific options.
For example, under 17 percent identified nicotine vapes as a smoking cessation tool, and only 27 percent knew that vaping is less harmful than smoking.
Substantially more identified NRT options like gum and patches as smoking cessation tools and knew that these are low-risk nicotine alternatives, though these students were still in the minority.
Happily, an overwhelming majority rejected as false the idea that if a patient has smoked for a long time, it is “too late” for them to stop—either because their health is already irreversibly affected, or because they would not be able to do so. Most also understood that people typically require multiple attempts before they can quit.
My survey data also reflect public demand for support to quit smoking. The students were already conducting community health care work in the course of their professional development. About half had come across patients seeking advice on smoking cessation—and almost 16 percent said they encountered such patients either “many times a week” or “a few times a week.”
This underlines what a vital moment a visit to a health care provider can be in a person’s life. It further emphasizes the importance of proactive engagement and tailored interventions from providers, to suit different individuals who want to quit.
I was left with an overall sense of the students’ potential openness to tobacco harm reduction.
Despite many misconceptions, and much uncertainty about recommending vapes and other harm reduction products, I was left with an overall sense of the students’ potential openness to tobacco harm reduction.
A sizable majority, for example, said they would be willing to attend training on smoking cessation strategies. This bodes well for the future.
The road to more rapidly reducing smoking-related harms in Rwanda is fraught with obstacles—as reflected by today’s scarce availability or knowledge of tobacco harm reduction products, and the absence of meaningful regulation.
But tomorrow’s knowledgeable health care providers can be critical sources of information for the public, and important advocates at a policy level.
If this future is to be realized, it is essential to educate the medical community in Rwanda—and far beyond, in a world where most doctors remain woefully misinformed.
Photograph of health visit in Rwanda by Davyimage via Wikimedia Commons/Creative Commons 4.0
