In low-income countries, smoking is often associated with low social and educational status. These consumers do not have the means to pay for advice and medication.
Tobacco use represents a heavy health and economic burden worldwide. The research valued that in 2019, around 8 million deaths were attributable to smoking. Tobacco also reduces years of healthy life : about 200 million disability-adjusted life years in 2019.
This health burden is accompanied by high economic costs, directly linked to the medical treatment of tobacco-related diseases and indirectly to productivity losses. Globally, the total economic cost of tobacco use was approximately 1,8% of global annual GDP in 2012. Global studies are rare because they require a lot of data.
Although overall tobacco consumption has decreases in most high-income countries since the 1970s, it has remained stable or increased in most low- and middle-income countries. Today more than 80% of smokers worldwide live in low- and middle-income countries, resulting in an unequal distribution of the disease burden.
This unequal distribution of the tobacco-related disease burden also exists within countries. In most countries, tobacco use is unevenly prevalent among the poor – the very people who can least afford health care and the financial costs associated with it.
Smoking is not only a question of smokers, but also of people who quit smoking. In countries with high income, it is mainly wealthier smokers who try to quit – and who succeed. In contrast, research on smoking cessation in low-income countries is scarce.
An survey that I co-wrote with Dr Laura Rossouw endeavored to fill certain gaps. We decided to measure inequalities in smoking cessation in eight countries in sub-Saharan Africa. 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 to quit and succeed were the wealthiest and the most educated. Inequalities in the ability to quit smoking were associated with socioeconomic status, urban or rural residence, and not knowing or believing that tobacco use leads to serious illness.
We suggest that the governments of these countries can do more to support socioeconomically disadvantaged smokers in their efforts to quit smoking. Their strategies should align with the guidelines set out in the WHO Framework Convention on Tobacco Control.
Providing subsidized medical assistance to smokers trying to quit could make these services more accessible to the poor. This would alleviate the health and financial burden disproportionate tobacco-related diseases from which they suffer.
Who uses tobacco?
Our analysis was based on representative national surveys of individuals aged 15 and over in each of the eight countries included in our sample. The Global Adult Tobacco Survey collects information on who uses tobacco and in what form, as well as demographic and socio-economic variables. This is a standard survey that allows countries to be compared.
We chose the eight sub-Saharan countries based on data availability. The oldest survey was conducted in 2012 in Nigeria and the most recent in 2018 in Tanzania. Each survey recorded information on thousands of people, whether or not they were tobacco users. It also showed who had tried to quit.
In all countries, tobacco users were more likely to belong to the lowest income group. In Uganda, Tanzania, Kenya and Botswana, more than 40% of current and former smokers earned less than one-fifth of the lowest income. In Cameroon, Ethiopia, Kenya, Senegal and Uganda, more than 50% of current and former smokers had no formal education.
Smokers who had tried to quit in the past year accounted for up to 53% of current smokers (in Botswana) and at least 29% (in Cameroon).
Our analysis showed that differences in wealth levels contributed to inequalities between former and current tobacco users. Education widens the wealth gap. Living in an urban area (as opposed to a rural area) also contributed to widening the gap in some countries, but not in Ethiopia, Senegal and Uganda. Tobacco-related health knowledge has also played a role in creating inequalities between wealthier and poorer smokers. The fact of being poorly informed about the consequences of tobacco on health mainly concerned people with a low level of education.
Our results showed that quit attempts – and successful ones – were concentrated among wealthier people and those with higher levels of education.
What helps smokers quit?
Among key policies include warnings against the dangers of smoking, banning advertising, help with quitting smoking and taxation of tobacco products.
The last Report on the global tobacco epidemic (2021) covers all 195 countries worldwide. It shows that progress has been made in implementing policies to reduce the demand for tobacco.
But of all the measures recommended to reduce the demand for tobacco, the following measures have made the least progress
- provide tobacco users with help to quit smoking
- the increase in tobacco taxes.
Many itself show conclusively that tobacco taxation is the most effective way to reduce tobacco consumption. But at present, of all the policies, the policies tobacco tax regimes based on best practices protect the fewest people in the world.
As for the offer of services smokers trying to quit: 55% of low-income countries offer no support. No low-income country offers the best performing services.
Tobacco taxation can be used not only to reduce the demand for tobacco, but also to generate income for efforts to help consumers quit smoking.
We must act
Governments have the opportunity to reap health benefits for their citizens and financial benefits for their countries by implementing evidence-based tobacco control policies.
Research shows that a healthy population is more productive and prosperous.