Despite the number of smokers in the world declining slightly over the last twenty years, Africa is one of the two regions to show increase in the number of smokers. This is of great concern and there are numerous efforts to empower communities with knowledge to make appropriate decisions regarding smoking. Professor Solomon T. Rataemane, a psychiatrist from South Africa, chaired this session on the diversity on tobacco harm reduction in Africa and called Mr. Fares Mili, a pneumonologist and addictologist from Tunisia, and Dr. Imane Kendili, a psychiatrist from Morocco and President of African Global Health, to give their perspectives.
At the session opening, Prof. Rataemane said that while 80% of smokers in Africa live in low- and middle-income countries, the allocation of budget for mental health-related issues is very small, and the focus is not so much on tobacco; it is mainly on alcohol, cannabis, and other drugs. It is challenging to gather enough research to convince governments that alternatives to smoking, while not perfect, are still much safer than regular cigarettes, Prof. Rataemane commented. Even though hospitals are full of people with chronic diseases linked to heavy smoking and drinking, this evidence alone often isn’t enough. Governments tend to ignore tobacco harm reduction if it’s seen as a separate issue, while there is also the fear of a possible hidden agenda. That’s why, in Kenya, the Harm Reduction Association was launched last year, to focus not only on tobacco, but on the overall harm reduction, including HIV, alcoholism, obesity, among other health issues. According to Prof. Rataemane, increasing research is the answer to this problem, so that governments can be advised on why it is important to have a tobacco harm reduction program.
Tobacco Harm Reduction in Africa as a public health requirement
In his speech about Tobacco Harm Reduction in Africa as a public health requirement, Mr. Fares Mili said that Africa is a continent with multiple dimensions of diversity and disparity and that the African tobacco landscape is very complex. Smoking rates vary significantly across the continent, from nations with very high prevalence (≥25%) to those with historically low rates (£10%). Despite a decline in the rates of smoking, the total number of smokers in Africa is expected to rise to 84 million by 2025, driven by population growth. The challenge includes both cigarette smoking and the widespread use of smokeless tobacco products that may be sniffed, chewed, sucked or applied to teeth and gums, which is common in some African countries. For many communities, tobacco farming is a vital economic activity, adding a layer of socioeconomic complexity to control efforts.
The MPOWER Strategy, the WHO framework for global tobacco control, is facing implementation challenges and is unequally implemented across African nations, due to significant systemic barriers, Mr Mili explained: 1) limited resources, 2) lack of trained healthcare professionals for cessation support, 3) lack of compliance with existing regulations, 4) illicit trade, and 5) economic and political instability. All these gaps have an inevitable human health cost, causing strain on healthcare systems and devastation of families and economies. The most vulnerable in Africa are the most afflicted: people with mental health concerns and marginalized communities with limited access to healthcare and education.
Tobacco harm reduction is a pragmatic public health strategy, Mr Mili said. It acknowledges that, while abstinence is ideal, providing access to less harmful alternatives can save lives. On the other hand, a policy that frames all nicotine products as equally harmful is a missed public health opportunity. Mr. Mili emphasized that tobacco harm reduction does not replace the WHO MPOWER framework; it is a crucial complement to it. He stressed the need for sense-based regulation, adult smokers’ access to alternative products, robust research in order to generate local data, and honest communication. “Adopting and integrating tobacco harm reduction strategies is not just an option; it’s a public health requirement for a healthier Africa”, Mr. Mili concluded.
Realities and Perspectives of Tobacco Harm Reduction strategies in Africa
In her speech on the Realities and Perspectives of Tobacco Harm Reduction strategies in Africa, Dr. Imane Kendili pointed out that, nowadays, health discussions are not just about addiction, non-communicable diseases, or infectious diseases, because many other issues, such as climate change, environment, food security, or water crisis, have been added to the picture.
She also emphasized the different cultural context in Africa, where 60-70% of the population are young people under 25 years of age, and where societies are moving from a traditional way of life to post-modernity, without the necessary intermediate steps that lead to maturity. As a result, women and young people are attracted by the new way of life, and instant pleasure plays a central role in their lives. Moreover, despite the adoption of new legislation, authorities are struggling to enforce smoking regulations in many African countries, where the reality is that people smoke everywhere and minors can easily buy conventional cigarettes. Finally, some countries, like Malawi, have a real economy based on tobacco production, and it is very difficult to change minds when the economy is based on tobacco production.
Therefore, it is not possible to implement the same policy pillars as in the rest of the world, Dr. Kendili noted. “We need to regulate, but not to imitate,” she said. Innovation and regulation cannot be applied in Africa as an imitation of the countries of the North, she concluded.
Discussion
Opening the discussion, Professor Rataemane reminded the audience of the positive effects of nicotine, such as aggression-reducing properties. He added that young people all over the world start smoking quite early and it is very difficult to turn them around without giving them data to make informed decisions. He also advocated for smoking cessation clinics as part of the armamentarium that we need to help people make better choices. To Prof. Rataemane’s question to the speakers about the common features between Morocco and Tunisia, Mr. Mili answered that it is “the use of cannabis”. Young people initiate tobacco and cannabis use at the same time, and that adds to the problematic situation. Tobacco is the first leading gateway to other substance use, he said. Prof. Rataemane commented that cannabis farming is widespread in some countries, like Malawi, but cannabis planting cannot be stopped without giving the farmers an alternative. Dr. Kendili agreed that there is a problem with cannabis all over the world, because it can be easily found everywhere. She pointed out that it is very important to know that cannabis use is linked to mental disorders and chronic pain. Moreover, she said, as traditional marriages between cousins were very common in Africa until recently, genetics in African people are different and the rate of mental health disorders due to cannabis is very high.
The Health Harm Reduction Manifesto
Dr. Kendili then presented the Health Harm Reduction Manifesto, the second book in a series that emphasizes the necessity to develop new public health policies. The book came out in 2025, written by more than 40 experts from 46 countries, with Dr. Kendili among the co-authors. It includes four chapters on tobacco harm reduction, but many other issues are also addressed, such as obesity and sugar consumption, climate change, vaccinations, etc. The book brings together stakeholders and policymakers from various domains, so that they can decide how we can pave the future of our nations and achieve health sovereignty, Dr. Kendili said.
Professor David Sweanor, also among the authors, commented that many things that we can do about health cost very little or nothing. “We do not necessarily need to build multi-billion-dollar hospitals or spend huge amounts on bio research”, he said and concluded that cost-effective health solutions are often overlooked and perhaps regions like Africa can lead the way in such discussions.