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Chapter 15 Tobacco in Africa: More than a health threat Yussuf Saloojee Tobacco control has not been assigned a high status as a public health concern in most of sub-Saharan Africa (SSA). Social and economic factors are therefore the main determinants of tobacco use on the continent. Urbanization, increased literacy, the entry of women into the workforce and higher disposable incomes are among factors facilitating the adoption of consumer patterns similar to those in higher-income countries, including increased cigarette smoking. ‘Across Africa the total lifestyle is starting to change’ claims the head of the advertising agency Saatchi Africa, Eric Franc. ‘There is a stronger move towards the western lifestyle as the pace of urbanization increases. People becoming more aware of luxury goods and consumer items they never had before’ (Koenderman 2002). Cigarettes, beer, soft drinks, cellular phones, and banking are the products most prominently advertised in African markets. On the other hand, the World Bank warns that the rapid spread of HIV/AIDS, dwindling aid and investment flows, and weak commodity prices threaten to undo the development gains achieved from 1970 to 1995 (World Bank 2002). Reduced economic growth will diminish business opportunities for the transnational tobacco companies. Africa cannot continue to ignore tobacco control issues if it is to avoid the ‘epidemiological trap’ with diseases of lifestyle adding to the toll of disease caused by poverty. This chapter presents an overview of tobacco use, trade, and health policy in SSA. Tobacco use in sub-Saharan Africa Due to low consumer purchasing power SSA has the lowest rates of cigarette consumption in the world. In 1963, it is estimated that fewer than 400 cigarettes per adult (aged 15+) per year were sold in this region; by 1995, consumption had risen to 480 (compared to a global average of about 1325) (World Health Organization 1999). Disposable income is a major determinant of cigarette consumption levels—there is positive relationship between gross national product (GNP) and average cigarette consumption per adult (Fig. 15.1). Cigarette usage is greatest in upper-middle income
268 TOBACCO IN AFRICA: MORE THAN A HEALTH THREAT countries like Mauritius and South Africa and least in low-income countries such as Ethiopia and Guinea-Bissau (World Bank 2001). It is estimated that about 21 per cent of adults in the region smoke cigarettes, compared to a global average of 33%. The prevalence of smoking is relatively low mainly because few women smoke cigarettes. Smoking prevalence appears to be highest in Nairobi (Kenya), Conakry (Guinea), and Namibia with high proportions of both men and women smoking. In several countries (Burkina Faso, Lesotho, Zimbabwe, Cote d’Ivoire, Nigeria) fewer than 2% of women report that they smoke, while more than half of all men smoke in Tanzania, Uganda, Guinea, Namibia, and Kenya (World Bank 2000) (Fig. 15.2). Cigarettes per annum 2000 1800 1600 1400 1200 1000 800 600 400 200 0 Ethiopia Guinea-Bissau Mozambique Series1 GDP US$ Cc DRCongo Malawi Uganda Gambia Ghana Tanzania Madagascar Nigeria Zimbabwe Zambia Mauritania Fig. 15.1 Cigarette consumption per adult and GDP per capita, 1999. per cent 80 70 60 50 40 30 20 10 0 Females Males Fig. 15.2 Smoking prevalence by gender in selected countries. Sierra Leone Angola Kenya Togo Cote d'Ivoire Cameroon Senegal South Africa Mauritius 4000 3500 3000 2500 2000 1500 1000 500 0 US $ per annum Rwanda ('92/4) Ethiopia ('95) Burundi ('96) Nigeria ('98) Burkina Faso ('92) Malawi ('96) DRC ('98) Swaziland ('94) Zimbabwe ('93) Zambia ('90) Seychelles ('94) Lesotho ('92) Niger (n/a) South Africa ('98) Cote d'Ivoire ('97) Algeria ('97/8) Mauritius ('98) Tanzania ('96) Uganda ('95) Guinea ('98) Namibia ('94) Kenya ('95)
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Tobacco and Public Health: Science
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Tobacco and Public Health: Science
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Preface Tobacco: The public health
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PREFACE vii The cigarette companies
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dramatically. Once more, I am not s
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it impairs quality of life for year
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documents and through litigation by
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PREFACE xv it will not succeed. Now
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Stratton, K., Shetty, P., Wallace,
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Contents Preface v C. Everett Koop
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27 Tobacco and pancreas cancer 479
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Contributors Amanda Amos Reader in
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Stephen S. Hecht University of Minn
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Cecily S. Ray Project Assistant Epi
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Abbreviations AAA Abdominal aortic
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Introduction The publication of thi
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Part 1 Tobacco: History
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Introduction Chapter 1 Evolution of
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RICHARD DOLL 5 However, little atte
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RICHARD DOLL 7 lung’ (Doll and Hi
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Table 1.1 Principal diseases caused
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Table 1.4 Manufactured cigarette co
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in 1995 was approaching the maximum
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References Adler, I. (1912). Primar
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Introduction Chapter 2 The great st
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MICHAEL J. THUN AND JANE HENLEY 19
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it seems likely that some of this v
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steady increase in lung cancer occu
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cigarette smoking in deaths from co
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the effects of smoking and smoking
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Lung cancer death rate (per 100,000
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Lickint, F. (1929). Zeitschrift fur
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Chapter 3 Dealing with health fears
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LYNN T. KOZLOWSKI AND RICHARD J. O
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Table 3.3 Selected cigarette advert
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Part 2 Tobacco: Composition
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Introduction Chapter 4 The changing
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ILSE HOFFMANN AND DIETRICH HOFFMANN
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Table 4.4 (continued) Carcinogens i
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Table 4.5 Standard conditions for m
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Table 4.7 Comparison of experimenta
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the lung in rats treated with NNK (
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serve as the scientific basis in su
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Senkus, M. (ed.) (1976). Leaf compo
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Introduction Chapter 5 Tobacco smok
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STEPHEN S. HECHT 95 Established pul
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STEPHEN S. HECHT 97 magnitude lower
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STEPHEN S. HECHT 99 generally great
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Table 5.1 1-Hydroxypyrene in the ur
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Table 5.2 NNAL and its glucuronides
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STEPHEN S. HECHT 105 Table 5.2 (con
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Table 5.3 Representative DNA adduct
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G No (Wang et al. 2001a) N 2 CHCH 2
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STEPHEN S. HECHT 111 N-Nitrosopyrro
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(Kozack et al. 2000; Seo et al. 200
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the DNA adducts resulting from toba
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Culp, S. J., Gaylor, D. W., Sheldon
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STEPHEN S. HECHT 119 International
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STEPHEN S. HECHT 121 Melchior, W. B
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STEPHEN S. HECHT 123 Rivenso, A., H
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Wang, M., McIntee, E. J., Cheng, G.
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Part 3 Nicotine and addiction
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Chapter 6 Pharmacology of nicotine
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JACK E. HENNINGFIELD AND NEAL L. BE
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Pickworth et al. 1995; Shiffman et
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American Caucasians and Hispanics (
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(US DHHS 2001). At doses delivered
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References JACK E. HENNINGFIELD AND
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Introduction Chapter 7 Behavioral p
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BRIDGETTE E. GARRETT ET AL. 151 How
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(Fischman and Foltin 1991). Another
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following repeated, infrequent and
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BRIDGETTE E. GARRETT ET AL. 157 oth
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BRIDGETTE E. GARRETT ET AL. 159 cli
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to tobacco product ingredients and
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BRIDGETTE E. GARRETT ET AL. 163 Gom
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BRIDGETTE E. GARRETT ET AL. 165 Ris
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Introduction Chapter 8 Cigarette sc
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JEFF FOWLES AND DENNIS SHUSTERMAN 1
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◆ The pressure drop of the filter
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Nitrosamines Nitrosamines are biolo
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Physical design features of cigaret
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Introduction Chapter 9 Nicotine dos
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world tobacco burden (World Health
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Table 9.2 The ranges of nicotine, n
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MIRJANA V. DJORDJEVIC 187 turing a
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Poland 19 1.4 n.a. n.a. 68−347 36
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MIRJANA V. DJORDJEVIC 191 cigarette
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MIRJANA V. DJORDJEVIC 193 Table 9.5
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MIRJANA V. DJORDJEVIC 195 MS wherea
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MIRJANA V. DJORDJEVIC 197 In recent
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MIRJANA V. DJORDJEVIC 199 Table 9.8
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MIRJANA V. DJORDJEVIC 201 Burns, D.
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International Agency for Research o
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Part 4 Tobacco use: Prevalence, tre
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Chapter 10 Tobacco in Great Britain
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Adult smoking PATTI WHITE 209 Since
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oys who were regular smokers report
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PATTI WHITE 213 cancer, and bringin
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Introduction Chapter 11 The epidemi
Page 250 and 251: since the late 1980s. In 2001, Phil
Page 252 and 253: YANG HONGHUAN 219 ◆ Among males,
Page 254 and 255: Table 11.1 Smoking among adolescent
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Page 260 and 261: Chapter 12 Patterns of smoking in R
Page 262 and 263: DAVID ZARIDZE 229 Ignatova et al. (
Page 264 and 265: DAVID ZARIDZE 231 Tyumen, respectiv
Page 266 and 267: References DAVID ZARIDZE 233 Alexee
Page 268 and 269: Chapter 13 Tobacco smoking in centr
Page 270 and 271: WITOLD ZATOŃSKI 237 The developmen
Page 272 and 273: especially post-Soviet countries, w
Page 274 and 275: No. of Cigarettes 3000 2500 2000 15
Page 276 and 277: WITOLD ZATOŃSKI 243 young men and
Page 278 and 279: DEATHS / 100,000 DEATHS / 100,000 7
Page 280 and 281: WITOLD ZATOŃSKI 247 According to d
Page 282 and 283: Unfortunately, available data on th
Page 284 and 285: Kaczmarczyk-Chalas, K., Gdulewicz,
Page 286 and 287: Chapter 14 The epidemic in India Pr
Page 288 and 289: aniseed, and musk, also available a
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Page 292 and 293: Prevalence among youth PRAKASH C. G
Page 294 and 295: treatment and premature death were
Page 296 and 297: Although tobacco control legislatio
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Page 302 and 303: In assessing tobacco use in Africa
Page 304 and 305: YUSSUF SALOOJEE 271 plug the gap th
Page 306 and 307: Table 15.2 Cigarette taxes as perce
Page 308 and 309: YUSSUF SALOOJEE 275 In recent years
Page 310 and 311: World Bank (2001). Economics of Tob
Page 312 and 313: Part 5 Tobacco and health. Global b
Page 314 and 315: Chapter 16 The future worldwide hea
Page 316 and 317: RICHARD PETO AND ALAN D LOPEZ 283 a
Page 318 and 319: UK male death rate at ages 35-69 ha
Page 320 and 321: Overview Chapter 17 Passive smoking
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Page 324 and 325: JONATHAN M. SAMET 291 a thousand de
Page 326 and 327: Table 17.2 Occupational ETS exposur
Page 328 and 329: Table 17.3 Nicotine concentrations
Page 330 and 331: portable piezobalance to sample aer
Page 332 and 333: JONATHAN M. SAMET 299 Fetal effects
Page 334 and 335: JONATHAN M. SAMET 301 Investigation
Page 336 and 337: Table 17.4 Summary of pooled random
Page 338 and 339: JONATHAN M. SAMET 305 also reported
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Page 342 and 343: Glantz, S. A. and Parmley, W. W. (1
Page 344 and 345: JONATHAN M. SAMET 311 O’Connor, G
Page 346 and 347: JONATHAN M. SAMET 313 US Department
Page 348 and 349: Introduction Chapter 18 Adolescent
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JOHN P. PIERCE ET AL. 317 would be
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JOHN P. PIERCE ET AL. 319 Indeed, t
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JOHN P. PIERCE ET AL. 321 reached i
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subsequent consumption. Most studie
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Burns, D., Garfinkel, L., and Samet
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JOHN P. PIERCE ET AL. 327 US Depart
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The epidemic Chapter 19 Tobacco and
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AMANDA AMOS AND JUDITH MACKAY 331 w
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AMANDA AMOS AND JUDITH MACKAY 333 T
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AMANDA AMOS AND JUDITH MACKAY 335 w
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AMANDA AMOS AND JUDITH MACKAY 337 p
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AMANDA AMOS AND JUDITH MACKAY 339 T
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AMANDA AMOS AND JUDITH MACKAY 341 o
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AMANDA AMOS AND JUDITH MACKAY 343 M
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such as Jewel and Madonna, who woul
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AMANDA AMOS AND JUDITH MACKAY 347 t
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particularly in developing countrie
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AMANDA AMOS AND JUDITH MACKAY 351 L
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Part 6 Tobacco and cancer
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Chapter 20 Cancer of the prostate F
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Table 20.1 Summary of results of ca
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Andersson et al. 1996 Sweden 256 ca
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Table 20.2 Summary of results of co
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cancer in younger or elderly men, w
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FABIO LEVI AND CARLO LA VECCHIA 365
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Summary Chapter 21 Laryngeal cancer
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12-year follow-up of the American C
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Hedberg et al. USA, 235, 81% P, 547
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cigarettes as compared to blond-tob
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of 3.78 and 11.47. An interpretatio
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Effect on survival In two studies f
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Cattaruzza, M. S., Maisonneuve, P.,
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USDHEW (1964). Laryngeal cancer. In
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Chapter 22 Smoking and cancer of th
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Table 22.1 Results from selected ca
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Asia Gao et al. 1994— Population
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EVA NEGRI 389 Ille-et-Vilaine, Fran
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Odds Ratio 2.5 2 1.5 1 0.5 0 0.30 2
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Garidou et al. 1996— Hospital ≤
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De Stefani, E., Barrios, E., and Fi
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Wynder, E. L. and Bross, I. J. (196
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Introduction Chapter 23 Tobacco use
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Table 23.1 Tobacco use and risk of
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Franceschi et al. Oral cavity, Oral
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Muscat et al. Oral cavity OR = 2.1
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Population-based case-control studi
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Lewin et al. Oral cavity, RR = 6.5
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TONGZHANG ZHENG ET AL. 411 the cont
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TONGZHANG ZHENG ET AL. 413 For smok
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TONGZHANG ZHENG ET AL. 415 per day
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TONGZHANG ZHENG ET AL. 417 than tha
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TONGZHANG ZHENG ET AL. 419 For exam
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TONGZHANG ZHENG ET AL. 421 decline
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Studies in India: Oral cancer is th
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carcinoma compared with other combi
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studies have demonstrated a positiv
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TONGZHANG ZHENG ET AL. 429 Garrote,
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TONGZHANG ZHENG ET AL. 431 Notani,
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Chapter 24 Smoking and stomach canc
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DAVID ZARIDZE 435 such as sex, age,
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DAVID ZARIDZE 437 (Kato et al. 1990
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DAVID ZARIDZE 439 respectively. The
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Gajalakshmi, C. K. and Shanta, V. (
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Pisani, P., Parkin, D. M., Bray, F.
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Introduction Chapter 25 Cigarette s
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attenuated in every study after con
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EDWARD GIOVANNUCCI 449 with a gener
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(Baron et al. 1994) of 352 colon ca
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(U.S. Dept. of Health Education and
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References EDWARD GIOVANNUCCI 455 A
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EDWARD GIOVANNUCCI 457 Kono, S., Ik
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Chapter 26 Smoking and cervical neo
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Tokuhata 1967* Williams 1977* Wigle
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Clarke 1985* Hellberg 1986* La Vecc
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ANNE SZAREWSKI AND JACK CUZICK 465
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case-control study nested in a scre
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five-fold risk of cervical cancer f
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(typically around two-fold), but be
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Introduction Chapter 27 Tobacco and
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Cigar, pipe, and chewing tobacco Wh
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Conclusion Overall, tobacco smoking
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Summary Chapter 28 Smoking and lung
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GRAHAM G. GILES AND PETER BOYLE 487
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quit for 20 years or more (Rogot an
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cancer and others where there is st
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Peto, R. (1986) Influence of dose a
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Chapter 29 Tobacco smoking and canc
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He further noted that case-control
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coefficients from the data in Table
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DIMITRIOS TRICHOPOULOS AND ARETI LA
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Epidemiology Chapter 30 Smoking and
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CRYSTAL N. HOLICK AND HARVEY A. RIS
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and at least the enteric variety of
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Chapter 31 Endometrial cancer Paul
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Table 31.1 Epidemiological studies
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studies (Terry et al. 1999, 2002a),
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Newcomer Population 740/2372 40-79
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PAUL D. TERRY ET AL. 531 levels, an
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Relative body weight Obesity is an
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Key et al. 1991 147 pre- and postme
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lood levels among current smokers,
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Table 31.7 Studies of cigarette smo
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of the association between cigarett
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Jensen, J., Christiansen, C., and R
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PAUL D. TERRY ET AL. 545 Weiderpass
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Part 7 Tobacco and heart disease
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citations of some of the best-known
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KONRAD JAMROZIK 553 because the dat
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KONRAD JAMROZIK 555 Fig. 32.2 Trend
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Table 32.3 Case-control studies of
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Table 32.5 Cohort studies of active
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Table 32.6 Effect of exclusion of p
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eadily addressed by cohort studies
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Specificity The entries in Table 32
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Table 32.8 Application of Bradford
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KONRAD JAMROZIK 569 arterial CVD re
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elationship goes beyond statistical
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Garland, C., Barrett-Connor, E., Su
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National Health and Medical Researc
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Part 8 Tobacco and respiratory dise
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Introduction Chapter 33 Chronic obs
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Many of the constituents in both th
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DAVID M. BURNS rate of growth in lu
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Death rates from COPD in smokers an
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Fraction of Excess Risk 1.20 1.00 0
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DAVID M. BURNS Higgins, M. W., Enri
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Part 9 Tobacco and other diseases
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Introduction Chapter 34 Smoking and
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ALLAN HACKSHAW 595 several mechanis
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Table 34.4 Studies that reported re
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Table 34.5 Cohort studies that repo
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than non-smokers; they have about h
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Table 34.8 Cohort studies that repo
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esults from cohort studies. There i
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ALLAN HACKSHAW 607 (DiFranza and Le
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Table 34.12 Cohort studies that rep
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Caries and tooth loss Because perio
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Table 34.16 Summary of disorders in
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References ALLAN HACKSHAW 615 Allar
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Johnsen, R., Forde, O. H., Straume,
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Seddon, J. M., Willett, W. C., Spei
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Part 10 Genetics, nicotine addictio
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Chapter 35 Genes, nicotine addictio
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Cotinine (ng/ml) 750 500 250 OXCHEC
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MICHAEL MURPHY ET AL. 627 of those
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MICHAEL MURPHY ET AL. risk associat
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Table 35.2 (continued) Gene map Chr
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MICHAEL MURPHY ET AL. pre-clinical
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Steps to carcinogenesis Exposure to
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DNA repair As previously alluded to
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MICHAEL MURPHY ET AL. Lichtenstein,
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Part 11 Tobacco and alcohol
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Table 36.1 Comparison of alcohol an
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Although gene therapy has rarely be
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20+ TABAC 5.1 10-19 0-9 3.4 12.3 0-
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Heavy drinking is known to cause ga
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Treatment issues and co-dependence
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ALBERT B. LOWENFELS AND PATRICK MAI
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Part 12 Tobacco control: Successes
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Introduction Chapter 37 Global toba
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NIGEL GRAY (sometimes at state leve
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NIGEL GRAY The first attempt to red
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per litre of smoke. Reduction of th
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Borland, R., Cappiello, M. and Owen
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Chapter 38 Lessons in tobacco contr
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entangling relationships with negot
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successful country advocates deeply
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Thus, when the opportunity arose, t
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Chapter 39 A brief history of legis
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Committee, mentioned above, little
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4. Tobacco and its related processi
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RUTH ROEMER 683 advertising and adv
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or shows, and distribution of free
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RUTH ROEMER 687 threat to the peopl
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RUTH ROEMER 689 The case was settle
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Another study by Harvard researcher
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At the end of 2003, 83 countries ha
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Chapter 40 Roles of tobacco litigat
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NGOs obtained sanctions against tob
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RICHARD A. DAYNARD 699 In a 1980s c
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RICHARD A. DAYNARD 701 Fourth, the
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even impossible. Such a statute pre
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RICHARD A. DAYNARD 705 Daynard, R.
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Introduction Chapter 41 Impact of s
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in this chapter, is evidence that s
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RON BORLAND AND CLAIRE DAVEY 711 Wh
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RON BORLAND AND CLAIRE DAVEY 713 On
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RON BORLAND AND CLAIRE DAVEY 715 ro
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you are subject, but this does not
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RON BORLAND AND CLAIRE DAVEY 719 to
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RON BORLAND AND CLAIRE DAVEY 721 fo
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RON BORLAND AND CLAIRE DAVEY 723 (E
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RON BORLAND AND CLAIRE DAVEY 725 th
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advanced. Although in countries lik
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RON BORLAND AND CLAIRE DAVEY 729 Da
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RON BORLAND AND CLAIRE DAVEY 731 Pr
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Introduction Chapter 42 Effective i
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PRABHAT JHA ET AL. 735 India (Gupta
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Average price or tax per pack (US$)
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PRABHAT JHA ET AL. 739 Bans on adve
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PRABHAT JHA ET AL. 741 Table 42.2 T
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PRABHAT JHA ET AL. 743 antismugglin
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Farrelly, M. C., Pechacek, T. F., a
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PRABHAT JHA ET AL. 747 Raw, M., Mc
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Part 13 Treatment of dependence
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Introduction Chapter 43 Treatment o
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Nocturnal sleep-disturbing nicotine
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MICHAEL KUNZE AND E. GROMAN 755 tob
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Fifteen different products were ide
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In summary, tobacco dependence amon
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medications for OTC sale in 1996, t
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MICHAEL KUNZE AND E. GROMAN 763 US
Page 798 and 799:
Chapter 44 Regulation of the cigare
Page 800 and 801:
as these correlate quite well with
Page 802 and 803:
NIGEL GRAY 769 within three major g
Page 804 and 805:
of carcinogens and toxins in its wa
Page 806 and 807:
Index abdominal aortic aneurysm see
Page 808 and 809:
aromatic amines 58, 60, 98 DNA addu
Page 810 and 811:
central and eastern Europe (CEE) (C
Page 812 and 813:
coronary thrombosis 5 see also myoc
Page 814 and 815:
epinephrine 169 epoxide hydrolase g
Page 816 and 817:
health professionals advice on smok
Page 818 and 819:
laryngeal cancer (Continued) animal
Page 820 and 821:
Morris, Philip 207 see also Philip
Page 822 and 823:
nursing home residents 718 nutritio
Page 824 and 825:
Polish Central Statistical Office (
Page 826 and 827:
smoke, tobacco (including cigarette
Page 828 and 829:
Sweden female smoking rates 330-1 l
Page 830 and 831:
United Nations agencies 680-1 Unite
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Tobacco and Public Health - TCSC Indonesia

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