The Minister of Health and Wellness Dr Edwin Dikoloti says the interests of public health will always prevail over the interests of the tobacco industry. This is because the government spends almost half a billion pula on treatment of tobacco-related ailments every year. The minister is concerned that as more people are initiated into tobacco use, more financial resources will be required for treatment of more people for tobacco-related afflictions, including heart troubles and asthma that also spread among non-smokers. He speaks with Staff Writer KEABETSWE NEWEL
Q: What exactly influenced the regulations on tobacco?
A: The high and increasing health and economic burden of tobacco use in Botswana as depicted by several studies conducted from 2002 to 2017 (Global Youth Tobacco Survey, 2002 and 2008; STEPS 2007 and 2014; Global Adult Tobacco Survey, 2017) motivated for the regulation of tobacco products. This is an indication of commitment to the protection of public health to curb tobacco-related diseases.
Botswana is also party to the World Health Organisation Framework Convention on Tobacco Control (WHO FCTC) which was signed and ratified in 2003 and 2005 respectively. As parties to the treaty, we are obliged to domesticate this into law.
However, it is worth noting that before Botswana was party to the WHO FCTC, there was the Control of Smoking Act of 1992 which had limitations. That legislation did not address emerging tobacco control issues and is not compliant with the WHO FCTC.
Q: With regards to tobacco use, addiction and damage, how does Botswana fare in terms of recent global trends?
A: Botswana, like other countries in Africa, is not spared from high morbidity and mortality as a result of tobacco use. The Botswana Global Adult Tobacco Survey (GATS) 2017 shows that overall 17.6 percent of adults, broken into 27 percent of men and 8.8 percent of women in Botswana, currently use tobacco. These statistics clearly indicate an alarming rate of addiction to tobacco by both children and adults in Botswana.
The Tobacco Atlas 2015/2016 indicates that 25.4 percent (194,300) of males use tobacco daily while 3.5 percent (27,000) females smoke tobacco in Botswana, which is more than the average in Medium Development Index Countries (HDI). In addition, 1.3 percent more boys and 0.8 percent more girls than the average in Medium HDI countries smoke in Botswana, according to the Tobacco Atlas 2015/2016.
Q: Can we say that we have a smoking addiction pandemic in Botswana or the situation here is not that bad?
A: Although we cannot say it’s a pandemic, yes, we can say we have a smoking addiction problem in Botswana. Botswana is currently undergoing rapid epidemiological transition indicated by a decline in infectious diseases and an increase in chronic non-communicable diseases, and tobacco use is a known risk factor for NCDs. According to the World Health Organisation (WHO 2014), the probability of dying between ages 30 and 70 years from the four main NCDs is 21 percent in Botswana.
The 17.6 percent prevalence of tobacco use in adults in Botswana is higher than any other African country. The GATS study also indicated that adults aged 20-34 years in rural areas and male adults aged 20-34 years are initiated daily into smoking at an average age lower than the legalised age of 18 years and above. Daily cigarette smokers aged 65 years and above smoke at least a pack of 20 cigarettes per day
The study also revealed that daily tobacco users aged between 15 and 24 and 65 years and older use tobacco within a shorter period of waking up. This data indicates that indeed we have a smoking addiction problem in Botswana.
Q: Share with us the number of people who die annually or live with critical medical conditions as a result of use of tobacco in Botswana?
A: Tobacco use is the leading preventable risk factor for NCDs. It is a risk factor for six out of the world’s eight leading causes of death and causes nearly 6 million deaths per year globally.
Nearly 2 000 Batswana are killed by smoking-related diseases (Global Burden of Disease, GBD 2015). According to the Tobacco Atlas 2016, 22 men die every week while eight women die weekly. The latest data, according to Institute of Health Metrics 2017, shows that 27 men die weekly while 11 women lose their lives weekly.
These studies indicate a growth in numbers of tobacco-related deaths. According to World Health Organisation’s Non-Communicable Diseases (NCDs) Country Profiles 2018, NCDs are estimated to account for 46 percent of all deaths in Botswana.
Q: The regulations also aim to stop public smoking because it affects non-smokers. How many people in Botswana are affected by passive smoking and how many of those are minors?
A: Exposure to tobacco smoke in various public places in Botswana was prevalent and ranged from 6.5 percent in health care facilities to 67.4 percent in bars and nightclubs.
Overall, the majority of non-smokers who visited bars and nightclubs (70.8 percent) reported exposure to tobacco smoke at those locations. Among non-smokers who worked in indoor workplaces, 11.9 percent were exposed to tobacco smoke at work and 10.6 percent of non-smokers were exposed to tobacco smoke at home.
Q: In your observation, are there certain public places that take the lead in contributing to passive smoking?
A: Yes, there are such places as per the GATS (2017) study. These include bus ranks, bars and night clubs, restaurants and workplaces.
Q: By regulating and prohibiting use of tobacco in certain public areas, what is the ministry trying to achieve?
A: Second-hand smoke exposure is a major concern to non-smokers in public places. There is no risk-free level of second-hand smoke exposure. Even brief exposure can be harmful to health. Studies have proven that second-hand smoke is more detrimental to health in comparison to smoking. The Ministry of Health and Wellness has a responsibility to protect public health, and this includes protecting the non-smokers from the devastating health effects of passive smoking.
Q: The regulations also prohibit the sale of single sticks of tobacco and only allows the sale of sealed packs. Please tell us the reasons for prohibiting the sale of tobacco sticks or unsealed packs?
A: It is a demand reduction measure. Single stick cigarettes are easily accessible and affordable even to minors. So its prohibition should help reduce initiation of into smoking and increases chances of quitting smoking due to affordability. Single stick cigarettes also make it impossible to communicate the health warnings that are printed on the packs.
Q: Businesses complain that regulations like the sale of sealed packs only will affect tobacco sales negatively, which will lead to businesses suffering. How do you strike a balance between saving Batswana from the smoking addiction while ensuring business continuity and economic development?
A: Public health interest will always prevail over tobacco industry interests. It is the duty of the Ministry of Health and Wellness to protect and save the lives of Batswana. Businesses, through alternative livelihood packages provided for by different sectors in the government, are encouraged to sell other commodities to compensate for the anticipated low tobacco sales because of people quitting use of tobacco products. The ultimate interest of the government is reduction in tobacco consumption by its citizenry.
Q: In Botswana currently, how would you say the tobacco industry contributes to the Botswana economy in terms of revenue, taxes and employment creation?
A: There are economic contributions from sales of tobacco products – jobs and incomes for employees, tax revenues for governments and enormous profits for cigarette companies. However, it is worth noting that the economic contributions of the tobacco industry cannot be compared to the deleterious effect that tobacco use has on health and the socio-economic status of families of smokers.
Tobacco use also imposes a heavy financial burden through medical costs, lost production due to illness and increased cleaning and property maintenance costs.
Q: In your assessment, how will the tobacco regulations affect the economy?
A: Tobacco regulation will benefit the country from large economic losses that arise from adverse health effects of tobacco use and the direct and indirect health costs that the government incurs in treating citizens from tobacco-related diseases and improving the socio-economic status of families. For example, according to the Botswana Global Adult Tobacco Survey (GATS) 2017, the average monthly expenditure for cigarettes was P789.10 This proves that smokers spend more money on tobacco, which in particular may exacerbate poverty among smokers and their families.
Q: How vulnerable are young people, especially minors, to passive smoking and tobacco advertising?
A: Tobacco companies must attract a new generation of tobacco users to survive. The industry constantly loses customers because many current smokers quit smoking or die from tobacco-related diseases. As a result, tobacco companies develop massive marketing campaigns to entice the youth to smoke and become long-term smokers. A comprehensive ban on tobacco advertising, promotion and sponsorship is one of the most effective policy measures to reduce youth tobacco use.
Smoke-free environments improve public health by reducing the public’s exposure to second-hand smoke, helping smokers quit or reduce their consumption, preventing the youth from taking up smoking and making smoking less socially acceptable.
Q: Annually how much does government spend on resources to treat smoking-related complications and addictions?
A: The Government of Botswana spends an estimated P447 million on medical expenses for treatment of tobacco-related ailments such as non-communicable diseases, examples being High Blood Pressure (BP), diabetes, cancer, and respiratory diseases. (Tobacco Atlas, 2015/6). As more people are initiated into tobacco use, the need for more resources is anticipated.
Q: Does the government have resources to continue treating smoking-related complications?
A: Botswana currently manages some of the tobacco-related complications through partnerships with private health practices. However, some complications are further referred to outside the country for specialty management. Furthermore, Sekgoma Memorial Hospital is currently under refurbishment for development into a rehabilitation centre. The government will continue collaborating with NGOs and other Civil Society Organisations to fight tobacco-related complications.
Q: The government is battling COVID-19 and it has been said that smokers are at an increased risk of succumbing to COVID-19. Would you please share the number of people who have died of COVID-19 as a result of smoking-related complications?
A: COVID-19 is an infectious disease that primarily attacks the lungs. Smoking impairs lung function, making it harder for the body to fight off coronaviruses and other diseases. Although we do not have the exact statistics of those of died of COVID-19 as a result of tobacco-related complications, a review of studies by public health experts convened by the WHO on 29 April 2020 found that smokers are more likely to develop severe disease with COVID-19 compared to non-smokers because their lungs are already compromised.
Comprehensive tobacco control laws have been shown to substantially improve indoor air quality, reduce second-hand smoke exposure, prevent smoking initiation by youth and young adults, help smokers quit and reduce chances of heart attack and asthma hospitalisations among nonsmokers. In addition to this, a reduction in the health bill expenditure due to tobacco-related complications is a motivating factor in the current tobacco bill as there is no safe level of exposure to tobacco smoke.