FOCUS ON TOBACCO PREVENTION AMONG NON-SMOKING ADOLESCENTS IN AFRICA; A CALL TO TOBACCO CONTROL EXPERTS

Tobacco use is a significant cause of preventable non-communicable diseases and avoidable deaths globally.¹ Tobacco and its smoke contain numerous cytotoxic and carcinogenic substances that are harmful to the oral and general health of users and those exposed to its smoke.² Some deleterious effects include cancers (oral, lung), cardiovascular, respiratory, and gum diseases.^2-5 The World Health Organization (WHO) puts the current global tobacco-related mortality at eight million,⁶ with 80% of the current smokers coming from Low and Middle-Income Countries (LMICs).⁶

Tobacco use has attained the level of an epidemic in many LMICs, including Africa.^7,8 The epidemic is sustained by the addition of adolescents to the current pool of tobacco users,⁹ with thousands of adolescents initiated daily.¹⁰ Adolescents are particularly vulnerable to proximal and environmental influences to use tobacco, and four out of every five adult smokers usually start smoking during adolescence.^2,9

Although the current prevalence of tobacco use among adults indicates that smoking prevalence is lower in the African region compared to other regions, the situation is changing. The current trend shows that the prevalence of tobacco smoking is reducing among adults in all the world regions (Americas, European, South-East Asia, Western Pacific) except for Africa and the East Mediterranean regions.¹¹ Consequently, Africa has been described as the future epicentre of the tobacco epidemic, representing "the greatest threat in terms of future growth in smoking." ¹² Modeling based on available data has predicted that while tobacco use in the African region is relatively low, compared to the other regions,^12,13 some African countries will experience up to nearly 40% increase by 2030.^8,14 There are early signs that the predicted change has commenced because while the prevalence of adult (male) tobacco smoking is a lot lower in Africa compared to other regions, this is not the case among the youth and adolescents.¹²

The African region has the highest proportion (23%) of adolescents,15 and is projected to record the highest increase in youthful population growth by 2050.¹⁶ Thus, for the tobacco industry (TI), it is strategic to deliberately target African adolescents in the bid to make Africa the next tobacco market.^12,17,18 The region also has the weakest tobacco control legislation, making it easier for the TI to exploit the vulnerability of the youthful population.¹² Early signs show that the TI influence is increasing as tobacco use among African adolescents and youths is increasing.¹² And while tobacco use in the African region is relatively low, compared to the other regions,^12,13 it has been predicted that some African countries will experience up to nearly 40% increase by 2030.^8,14

While the prevalence of tobacco use among adolescents is increasing, the prevalence of non-tobacco users who are susceptible to tobacco uptake is even higher.^19,20 Susceptibility to tobacco use is the lack of firm decision not to engage in the habit.²¹ Because susceptibility is a significant predictor of uptake, this group of people are at a higher risk of initiating and sustaining tobacco use.²²

A major tactic of the TI to make adolescents susceptible and initiate the habit is deception. They fail to provide accurate information about the harmful content of tobacco products, giving out the perception that they are not/less harmful.¹² This deception engenders poor knowledge among adolescents about the harm posed by tobacco products. Therefore, the positive perception of tobacco use by adolescents is often strongly related to their poor knowledge and low self-efficacy.^23-25

This pattern of increasing tobacco susceptibility and use among African adolescents calls for urgent attention. Unfortunately, ongoing tobacco control efforts in many African countries are directed towards tobacco cessation with limited success.²⁶ This has been partly because tobacco use is an addictive habit due to the nicotine content; hence, difficult to stop.²⁷ In addition, the high cost and lack of access to pharmacological intervention, which significantly increases cessation rates when combined with health education/counselling, worsens the situation.²⁸

However, reducing the burden of tobacco use in Africa will not only involve making current users quit (cessation) but must also include preventing non-users from initiating the habit. The latter is an area that we feel tobacco control experts must begin to pay more attention. While tobacco cessation greatly reduces mortality among those already sustaining tobacco use, tobacco prevention has a wider population-level effect that is rapidly scalable. Studies have shown that while educational intervention may fail to make adolescent smokers quit, it could reduce the proportion of those susceptible.²⁹ Susceptible adolescents are still non-smokers who are not addicted to tobacco use. Hence, intervening has a higher chance of success.^29,30 Thus, the parlance that "prevention is better than cure" is more critical for African countries in reducing the burden of tobacco use in the region.

Similarly, as opined by Blecher and Ross,¹² focusing on preventing tobacco uptake is a more pragmatic goal in Africa. The low prevalence of tobacco use in many African countries requires a pure prevention strategy.¹² This approach is not only appropriate, but they are also cost-effective. The economic cost of smoking is avoided, and the associated better health outcome of the populace will positively influence economic activities at country levels.¹² Pierce and others,²¹ advised that preventive intervention should be targeted at never-smokers. According to them, "smoking prevention programs should either prevent target groups from becoming susceptible to smoking or prevent susceptible adolescents from progressing to experimentation."²¹

To offer effective preventive intervention targeted at susceptible non-smokers in Africa, adequate information about this group is needed, and this is currently lacking. Only a few studies have examined adolescents' susceptibility to tobacco use in Africa,^20,29,31 and even fewer have assessed the effectiveness of educational interventions in preventing tobacco uptake among them.³² Considering that Africa is already facing enormous economic and health challenges from the tobacco burden, a further increase in tobacco use in this region will be devastating. Hence, tobacco control experts in African countries should focus on preventing the most vulnerable population group - adolescents, from initiating the habit. If they can do so successfully, about 80% of smoking during adulthood would be prevented. This would improve African countries' economic viability, leading to increased productivity from reduced tobacco-related mortality and reduced expenditure on tobacco-related diseases.