Tobacco use is costly, but so is quitting. Surveys of 8 African countries show who needs help

Tobacco use imposes a large health and economic burden worldwide. Research estimates that, in 2019, about 8 million deaths were attributable to tobacco smoking. Tobacco also reduces years of healthy living: about 200 million disability-adjusted life years in 2019.

This health burden comes with high economic costs, directly through medical treatment for tobacco-related diseases, and indirectly through productivity losses. Globally, the total economic cost of smoking amounted to around 1.8% of the world’s annual GDP in 2012. Global studies are rare because they are so data intensive.

Though overall tobacco use has been declining in most high-income countries since the 1970s, it has been stable or rising in most low- and middle-income countries. Today, more than 80% of the world’s smokers live in low- and middle-income countries, resulting in a skewed burden of disease.

This skewed burden of tobacco-related disease exists within countries too. In most countries, tobacco use is disproportionately prevalent among the poor - the very people who can least afford to finance the healthcare and financial costs associated with it.

Tobacco use is not only about who smokes but about who quits. In high-income countries, it’s mostly wealthier users who attempt to quit – and who succeed. But research on cessation in lower income countries has been scarce.

A study I co-authored with Dr Laura Rossouw set out to fill some gaps. We decided to measure inequalities in tobacco cessation in eight sub-Saharan African countries. Using the most recent Global Adult Tobacco Surveys in Botswana, Cameroon, Ethiopia, Kenya, Nigeria, Senegal, Tanzania and Uganda, we found that the people most likely to try and succeed at quitting were wealthier and better-educated individuals. Inequalities in ability to stop using tobacco were associated with socio-economic status, urban or rural residence, and not knowing or believing that tobacco consumption leads to serious illness.

We suggest that governments in these countries can do more to support socio-economically disadvantaged smokers in their efforts to stop using tobacco. Their strategies should be aligned with the guidelines outlined in the World Health Organization’s (WHO) Framework Convention on Tobacco Control.

Providing subsidised medical support to smokers trying to quit could make these services more accessible to the poor. This would ease the disproportionate health and financial burden of the tobacco-related illnesses that they suffer.

Who uses tobacco

Our analysis used nationally representative surveys of individuals aged 15 and older from each of the eight countries included in our sample. The Global Adult Tobacco Survey captures information about who is using tobacco and in what form, as well as demographic and socio-economic variables. It’s a standard survey design which allows comparison of countries.

We chose the eight sub-Saharan countries based on availability of data. The earliest survey was conducted in 2012 in Nigeria; the most recent, in Tanzania in 2018. Each survey recorded information on thousands of individuals – tobacco users and non-users. It also showed who had attempted to quit.

Across the countries, tobacco users were more likely to be in the lowest income group. In Uganda, Tanzania, Kenya, and Botswana, more than 40% of current and past tobacco users were in the lowest fifth of the income spectrum. And in Cameroon, Ethiopia, Kenya, Senegal and Uganda, more than 50% of current and past tobacco users had not completed any formal education.

Smokers who had tried to stop in the past year made up as many as 53% of current smokers (in Botswana), and at least 29% (Cameroon).

Our analysis showed that differences in wealth status contributed to inequalities between former and current tobacco users. Education widened the wealth-related gap. Living in an urban area (versus rural) did so too in some of the countries but not in Ethiopia, Senegal and Uganda. Tobacco health knowledge also played a part in creating inequality between richer and poorer smokers. Being misinformed about tobacco’s health consequences was concentrated among individuals with lower levels of education.

Our results showed that attempts to stop using tobacco – and successful attempts – were concentrated among wealthier individuals and those with higher levels of education.

What helps smokers quit?

The WHO’s guidelines, ratified by 182 countries, show which policies work best to reduce tobacco use. The WHO also monitors which countries are using the policies.

Among the key policies are warning about the dangers of tobacco use, banning advertising, offering help to quit, and taxing tobacco products.

The most recent WHO Report on the Global Tobacco Epidemic (2021) covers all 195 of the world’s countries. It shows there has been progress in following policies to reduce tobacco demand.

But of all the recommended measures to reduce the demand for tobacco, the least progress has been made with:

• offering tobacco users help to quit

• raising tobacco taxes.

A large body of evidence conclusively shows that tobacco taxation is the most effective and efficient way to reduce tobacco consumption. But right now, out of all the policies, best-practice tobacco tax policies protect the least number of people in the world.

As for offering services to tobacco users trying to quit: 55% of all low-income countries offer no support at all. No low-income countries offer the best-practice services.

Counselling and medication can more than double a tobacco user’s chance of successfully quitting. But paying for it is a challenge.

There’s an opportunity to use tobacco taxation not only to reduce the demand for tobacco, but also to generate revenue for efforts to help users quit.

Action is required

Governments have an opportunity to reap health benefits for their citizens, and financial benefits for their country, through implementation of evidence-based tobacco-control policies.

Research shows that a healthy population is a more productive and prosperous one.