With nearly 80 percent of the world's users of risky forms of tobacco living in lower-middle-income countries (LMICs), the poor uptake of safe nicotine products in these countries remains a cause for concern.
A myriad of shortcomings have enabled the tobacco industry to expand its markets in at least 137 World Bank rated LMICs by capitalising on economic growth, changing social norms and population demographics. Many LMICs have weaker smoke-free policies and fewer restrictions on tobacco advertising compared with other world regions and these have resulted in rising tobacco prevalence across countries classified under the LMICs category.
The Seventh Tobacco Atlas Report of 2022 noted that some countries, mostly in Africa, are experiencing increases in smoking prevalence and the trend is likely to occur in many countries, especially countries with the Lowest Human Development Index (HDI), due to income growth and increasing cigarette affordability as well as the tobacco industry's strategy of aggressive marketing in those countries. According to the report, while global smoking prevalence decreased from 22.7 percent in 2007 to 19.6 percent in 2019, in many poorer countries there was either no change or prevalence increased.
Tobacco companies have over the years been championing the roll-out of safer, novel smoke free nicotine products with the aim of reducing morbidity and mortality associated with tobacco. Amongst these products are heated tobacco products, E-vapour products and oral smokeless products. These products provide nicotine without burning, making them a much better alternative to cigarettes.
Despite the fact that tobacco companies have a presence in most LMICs, Africa included, the conspicuous absence of tobacco cessation products and safer nicotine products on the African continent cannot go unnoticed. According to the World Health Organisation (WHO) countries in the African Region are experiencing an increasing rate of tobacco use. The fast growth of the population in Sub-Saharan Africa and an increase in consumer purchasing power is leading to larger and more accessible markets in Africa. In addition to that there are the intensive efforts by the tobacco industry to expand African markets.
Speaking during a Global Nicotine Forum panel that set out to explore whether the Tobacco industry transformation was really reaching LMICs, Joseph Magero, a Tobacco Harm Reductionist from Kenya said African smokers were mostly willing to switch from combustible to non-combustible nicotine products but cost was a huge barrier.
"In Africa as a continent, at the moment has about 77 million smokers. There are about a quarter of a million Africans dying from smoking related diseases. What is the tobacco industry doing since they are actively involved on the African continent? We at the moment cannot afford cessation services including products which are recommended by the World Health Organisation (WHO) like Nicotine Gum and Pouches which cost about US$45 to US$50 dollars and most smokers cannot afford that. Smokers are willing to switch and we keep hearing about these products but we have no access to them."
However, other experts believe that while tobacco companies might have intentions to invest in safer nicotine products in low middle-income countries, the policy inconsistencies and regulatory uncertainly in most LMICs, was a hindrance to a speedy tobacco transformative process. Countries like India, Uganda, Ethiopia and many others LMICs have since issued bans on the possession, trade and marketing of E-cigarettes.
Atul Agarwal, an expert in Strategy and Operations primarily working in life sciences, consumer and industrial products sectors, said corporates hate uncertainty.
"It is a fact that most tobacco companies have significant profits from the LMICs. It is a big source of revenue and profit for Tobacco companies. The other factor is that there is the Framework Convention on Tobacco Control (FTCT) guidelines and so on but these countries have limited capacity to enforce those guidelines.
"There is also a lot of regulator uncertainly which also negatively impacts the commitment of tobacco companies. The one thing that corporations don't like is uncertainty. Whether it's the economic uncertainty or the regulatory uncertainty, they don't like that," said Agarwal.
He however said there is need to further interrogate the reluctance of tobacco companies to roll out and make safer nicotine products available in LMICs where it is legal to sell smoke free and safer nicotine products.
Dr Sud Patwardhan, the co-founder of the Centre for Health Research and Education said, "It is absolutely clear that consumers all around the world are demanding reduced risk products. They may not express it all around the world but that unexpressed sentiment is very, very strong, and it is also a fact that most tobacco companies have a significant revenue and profit source in low-and-middle-income countries - if you look at India or Indonesia, or many countries in Africa, many countries in South America, [these countries are] big revenue earners.
Meanwhile, Flora Okereke, the Head of Global Regulatory Insights and Foresights at British American Tobacco (BAT) echoed that tobacco transformation in LMICS has largely been slowed down by regulatory induced resistance.
"I believe in health equity and therefore, technically, safer nicotine products should be available and accessed by everyone who needs them. However, that is not reality is it? In the 60 markers that we have, the top 12 THP markets, four of them are actually in the LMICs. If it wasn't for the pushback in the markets, some of our smoke free products would be in the 21 COMESA markets today but that could not happen because of the regulatory pushback," said Okereke.
She added that there are several factors to consider before launching products in any market including LMICs. These include regulation, cost (price), local consumer taste and knowledge, among others.
"There are challenges. A lot of the LMICs have health priorities that go beyond thinking about smokers. Probably 16 of these countries that are classified as LMICs have smoking prevalence that are less than 10 percent but they have high incidence of child deaths, traffic deaths, sanitary issues, Cholera and Malaria. Thinking that they are going to focus on few smokers and not these priority issues is a little far-fetched."
While tobacco taxes have been viewed as the most cost-effective way to reduce tobacco use and health care costs, especially among youth and low-income people, various speakers at the GNF concurred that novel tobacco products should be regulated and taxed differently from cigarettes to encourage adult smokers to move to these products.
