There are over 1 billion smokers in the world, and 80% of them are living in developing countries. Determined to prevent disaster, Senegal is taking the lead in the war against tobacco.
The air in Dakar is far from clean. It is thick with sand and dust, not to mention the exhaust from old taxis and cars rapides from another era. But, unlike other African cities, the capital of Senegal can boast that it is not overrun by cigarette smoke. There are no smokers outside the airport, no cigarette butts on the ground, no cigarette packs for sale in the shops.
Only a few toubabs—the local term for a person of European descent—stroll along nonchalantly, cigarette in hand, in this city that is also home to many nongovernmental organizations (NGOs) and international institutions. Incidentally, it was due to spending time with foreign workers and tourists that Moussa, 27, started smoking. Speaking with me on the beach in Ngor, a fishing village located to the north of Dakar, he admits to lighting one up from time to time, out on the water in his pirogue. "I often take toubabs out fishing, and they always offer me a cigarette," he says, laughing. "But it's still pretty new around here. My father, for example, never smoked—it was too frowned upon."
It's worth noting that in this country, which is 95% Muslim, smoking is not among the traditions. "In the more religious neighbourhoods, it's not tolerated. You don't smoke in front of the elderly, for example, and smoking is totally taboo for women," says Abdoulaye Diagne, a specialist in the war on tobacco and Director of the Consortium pour la recherche économique et sociale (CRES), which brings together researchers from the Université Cheikh Anta Diop de Dakar.
Indeed, in Senegal, where approximately 11% of men identify as smokers, the same is true of only 0.4% of women, according to a 2015 study conducted by the Agence nationale de la statistique et de la démographie, in partnership with the World Health Organization (WHO). These numbers are low compared to the prevalence of smoking worldwide (approximately 25% of men and 5% of women smoke, according to a study published in The Lancet in April), or to the prevalence in certain Asian countries (around 60% of men in Indonesia and China smoke).
This global epidemic, which kills 6 million people each year, still seems to be under control in African countries—with a few exceptions, notably in the Maghreb and in South Africa.
But it is this low prevalence that worries anti-smoking organizations, researchers, and governments, explains Anna Gilmore, Professor of Public Health at the University of Bath and research associate at the UK Centre for Tobacco and Alcohol Studies.
"The African market poses the largest growth opportunity for the tobacco industry. And as African economies are growing stronger, the industry knows that it will be able to increase prices and profits," says the author of numerous articles on the tactics used by this industry.
Chased out of wealthy countries through legal action, legislation, taxes, and advertising restrictions, the tobacco giants are stepping up their marketing strategies in developing countries. And it's working: between 2000 and 2015, tobacco use gained ground in 27 countries, 16 of which are located in sub-Saharan Africa—and Senegal is one of them.
"The smoking epidemic is spreading to the poorest countries. The industry targets countries that don't have legislation in place to protect their population," says Oumar Ndao, assistant coordinator for the national anti-tobacco program at Senegal’s Ministry of Health and Social Action.
Due to this combination of factors, the cigarette companies are doing just fine, thank you. They even saw their best sales volumes since 2006 in 2015, with 5.5 billion cigarettes sold (frighteningly, that's the equivalent of 770 for every person on Earth!). This success is largely due to the growing demographic in developing countries...and to how young these new smokers are. "This is clearly the goal: Africans younger than 25 years of age represent a market of 700 million people," says Oumar Ndao.
Recognizing the threat, the Senegalese government took action, voting in 2014 for anti-smoking legislation that is among the strictest in the world. This legislation, which came into effect in the summer of 2016, prohibits smoking in public places, requires that health warnings be included on tobacco packaging, prohibits the sale of cigarettes to minors and within 200 metres of schools, and bans all forms of advertising for tobacco products.
Taboos are falling away
Despite these religious and legal safeguards, youth in Senegal are succumbing, bit by bit, to the industry's siren song. "Young people are smoking a lot of shisha [editor's note: hookah] which lends an aromatic and sweet taste to the tobacco. This is new, and it's worrisome," says Mamadou Bamba Sagna, regional coordinator of the American NGO Campaign for Tobacco-Free Kids in Dakar.
These water pipes, which are at least as likely as cigarettes to cause addiction, are helping to give tobacco use an acceptable and trendy image.
And it's clear that in Dakar, the mindset is changing. Even Senegalese women are lighting up: according to a survey conducted in 2013, 6% of girls aged 13 to 15 years old were using tobacco products (along with 15% of boys).
All you have to do is go to Médina, a working-class area, to see that it's true. "Before, people would hide it. Now, it's less taboo," explains Modou, an artist who goes by the name "Mod Boye". "More and more teens are smoking outside of the high schools." The young man, who runs a street artists' collective and knows the area like the back of his hand, greets everyone he meets.
In front of hundred-year-old buildings, a few sheep wander the quiet streets, and men sit on benches, leisurely chatting and smoking. Here, far from the main roads, people seems less concerned about religious dictates. "Everybody can afford cigarettes," Modou continues. You can buy one for 25 CFA francs [editor's note: approximately $0.05] in any shop."
Only one? The practice is common and it's legal: merchants open the packs and sell the "smokes" individually. Sure enough, Modou hands a coin to the merchant on the corner, whose kiosk opens onto the street, and comes back with an Excellence cigarette (the local brand), "cheaper than Marlboros."
Being able to buy cigarettes individually makes tobacco accessible for any budget, and makes it possible for the poor, for teens, and for children to smoke. And it's no less of a financial trap, in a country where monthly earnings average around $125. A number of WHO studies have shown that cigarettes can take up as much as 40% of a poor household's budget, thus reducing by just as much those resources remaining for the children's health, education and food, according to CRES researchers. A real barrier to development.
"There is a pretty strong connection between tobacco and poverty. In addition to health issues, tobacco also comes with an opportunity cost: what could have been paid for instead? How much work time would be gained? What's more, in Senegal, families typically depend on a single breadwinner: if the breadwinner falls ill, the standard of living plummets," explains Nafissatou Baldé, economist and coordinator of the tobacco project launched by CRES in 2008.
The tax handle
The Consortium, funded by Canada's International Development Research Centre (IDRC), has a clear mission: making tobacco less accessible. In other words, convincing the government to raise taxes. With a pack of cigarettes currently retailing for just $1, there is plenty of leeway!
"A number of studies have shown that increasing taxes on tobacco products is the most effective—and cheapest—way of reducing smoking. It delays the onset of smoking, reduces consumption, even motivates smokers to quit, and generates tax revenue for the State," continues Ms. Baldé.
On paper, this measure seems simple enough to implement. In practice, however, it is an uphill battle. According to the evidence, the WHO states that just 10% of the world's population live in countries where taxes on tobacco are considered as deterrents.
"There are various tax systems: flat-taxes (which are the same for all products), taxes that correspond to a percentage of the cost of the pack (which therefore increases with inflation), or a combination of the two. To be effective, the tax must have an impact on the price, be easy to apply, and take inflation into account," says Nafissatou Baldé. Above all, it must win over the decision-makers, by showing them that higher prices will make up for decreased sales. Better still, by showing them that the war on tobacco can fill the State's coffers.
"To do this, we need to know the costs of tobacco use that are paid for by the State, by patients, by society in general," says professor Abdoulaye Diagne, CRES director and winner of a 2014 WHO award for his exceptional contribution to tobacco control.
Fittingly, his team has just launched a study to assess the health costs associated with tobacco use in 15 hospitals throughout the country. "We need solid evidence," he says, "since the tobacco industry argues that the sales revenue and the jobs created outweigh the healthcare costs." When questioned on this point, Philip Morris International, the corporation that provides products to more than 20 countries in Western and Central Africa, did not respond.
Although the manufacturers' rhetoric has been refuted point-by-point by numerous scientific studies, it continues to succeed. "The industry's arguments are ingrained in the decision-makers' minds: they're worried about job losses, even though it is a highly automated industry; they say that taxes increase the risks of fraud and smuggling, yet these issues are really about crime and customs measures," laments Nafissatou Baldé, adding that "the industry has connections within government."
An unfair fight
The four tobacco giants (British American Tobacco, Philip Morris International, Imperial Tobacco, and Japan Tobacco International) spare no expense in their efforts to open up new markets. In this respect, Anna Gilmore has shown that communities in developing countries are exposed to 81 times more tobacco ads than those in developed countries.
Furthermore, at the end of 2015, a British documentary revealed that British American Tobacco was guilty of large-scale corruption in Eastern Africa, bribing politicians and civil society to oppose tax increases, among other things. Until recently, in Senegal, Philip Morris funded sporting events and parties at bars, distributed t-shirts, etc. And in many countries, industry representatives hand out cigarettes by the shovelful to 13 to 15-year-olds.
More subtly, cigarette companies have mastered the art of supporting noble causes. Funding medical equipment, supporting children's education, improving access to clean water: they rely on "social and economic responsibility" to improve their image. "Recently, the industry provided financing for a group of 1,000 women vegetable farmers in Dakar,"explains Oumar Ndao.
But there is hope. "Despite the intense lobbying and the misconduct, which make any action incredibly difficult, huge efforts are being made in Africa to strengthen tobacco control," says Anna Gilmore.
With its legislation (even though it is still working on enforcing it), Senegal is a model on the continent. And the CRES team's determination has played a big part in that. In 2014, the Consortium also succeeded in passing an anti-tobacco statement in the 15 member countries of the Economic Community of West African States (ECOWAS) and the West African Economic and Monetary Union (WAEMU). The idea? Standardizing—and increasing(!)—taxes on tobacco throughout the region. "It's not easy to get 15 countries on the same page! Especially since Internet access is patchy in some places and the Ebola crisis prevented us from holding meetings," says Nafissatou Baldé.
"The advantage for us is that we can still curb the market, unlike the markets that are more established, like those in Asia," she says.
But there is still a long road ahead to ensure that this statement doesn't fall dead in the water. In countries struggling with alarming rates of infectious diseases, malnutrition and often unstable political situations, the chronic illnesses caused by smoking seem less urgent in the eyes of decision-makers. "Poor countries are 'short-termists,'" laments Oumar Ndao.
Preventing a health crisis
Nevertheless, tobacco use is a ticking time bomb. According to the WHO, by 2030, 80% of deaths caused by tobacco will occur in low- or middle-income countries.
"Here, the health systems are not equipped to deal with chronic illness. It is estimated that, for every 10 people who require chemotherapy, only three will be able to receive it," explains professor Diagne.
The poor are obviously the first to suffer. "In Senegal, patients are responsible for covering all of the costs, from consultation to treatment. Often, a cancer diagnosis is never made, because the patient cannot afford the tests. They request a sedative for the pain, and you never see them again," says Dr Ulrich Combila, a respirologist at the Centre Hospitalier National Universitaire Fann-Dakar.
In a 700-page report released at the start of 2017, the WHO estimated that approximately 226 million smokers live in poverty. It is for their protection, first and foremost, that tax measures must be put in place, states the organization, even if some fear that this may add insult to injury. "The people who smoke the most already can't afford to. The degree of addiction is so high that, no matter what the price, they will pay it!" fears Combila, pointing out that the population must also be educated about the dangers of smoking, and that those already addicted must be helped to quit.
In Médina, Modou enters a small cinder-block structure, with only a curtain for a door, and introduces Jim, an old friend with a toothless grin. It is after 10 a.m., he hasn't even had his breakfast yet, and he lights an umpteenth cigarette. When asked how long he has been a smoker, he laughs. "Since forever! But it's okay, I still have a little breath in me," he replies. Even if a pack costs 2,000 CFA francs [$4.35], I would still buy it!" No doubt the tobacco industry has a few good years ahead of it yet
Africa needs statistics
More than ever before, in the era of "alternative facts", researchers need evidence, figures, and statistics to rely on. But such data are sorely lacking in Africa.
"Except in South Africa, there is a general lack of national data. The majority of countries do not conduct regular surveys of their citizens, outside of schools and hospitals," explains Catherine Kyobutungi, an epidemiologist and Director of Research at the African Population and Health Research Center (APHRC), in Nairobi, Kenya.
This non-profit organization, which receives funding from IDRC, conducts numerous studies on the continent (mainly in health and education), and advocates for authorities to rely on scientific evidence to make decisions.
This is also the goal of the CRES in Dakar, which has just launched a survey to assess the health costs associated with tobacco use at 15 hospitals in Senegal (see our report entitled Smoking: Africa Fights Back). "We are going to document cardiovascular and respiratory illnesses, as well as cases of lung cancer and laryngeal cancer, collect data on patients' tobacco use, and assess the direct costs (medication, consultations, staff salaries, tests) and indirect costs (lost wages, premature death)," explains Papa Yona Mané, an economist and project officer at CRES.
It's an arduous task, since the hospitals don't have computerized records. The data will have to be collected manually over a period of three months, with the help of two doctors per hospital, using paper questionnaires. We have no choice, if we want to convince the government that smoking comes with huge costs. "The 'Achilles' heel' of the war on tobacco in Africa is the lack of statistics: we hardly have any figures to show," says Oumar Ndao, of Senegal's Ministry of Health and Social Action.
Indeed, even official statistics, whether from governments, the World Bank or the WHO, should be taken with a grain of salt. "More often than not, they are extrapolations made from partial data. For example, if they have figures on tobacco use in Kenya, the WHO will propose estimates for Tanzania, Uganda, etc.," says Kyobutungi.
Besides being a roadblock to improving governance, the lack of statistics hinders assessment of a population's degree of poverty, health status and access to basic services, and hinders achievement of international development goals.
The original French version of this article was originally published in the June 2017 edition of the magazine Québec Science.