Are Oral Nicotine Products Africa’s Ideal Smoking Cessation Intervention?

Cigarette smoking represents the most important source of preventable morbidity and premature mortality in Africa. Approximately 250,000 deaths annually are caused by cigarette smoking in Africa. The World Health Organization (WHO) states that 80 percent of the world’s more than one billion smokers live in low-and middle-income countries. While the number of smokers in Africa is still lower than North America and the East Mediterranean, that number is growing at the fastest rate in the world.

Rapid growth of the population in Sub-Saharan Africa and an increase in consumer purchasing power contributes to a projected massive smoking-related burden of disease. The WHO also forecast a doubling of deaths related to tobacco use in low- and middle-income countries between 2002 and 2030.

Current strategies are inadequate to curb the rise of tobacco use in Africa. Tobacco control efforts on the continent have concentrated on increasing tobacco taxes, restricting or banning advertising, adding or expanding warning messages and restricting smoking in public areas – advocating just quitting, without offering a viable alternative.

Majority of current cigarette smokers in Africa struggle to quit without any aid. The currently available medically licensed cessation products (if any) are falling short on delivering and sustaining smoking cessation in nearly 80% of the cases where they are prescribed. To complement these current cessation aids, the principle of tobacco harm reduction, where adult users of risky forms of tobacco eventually completely switch to non-combustible nicotine-containing products, can be applied to achieve and maintain cessation. There is an expectation that switching to non-combustible clean nicotine-based products will lead to substantial disease risk reduction if accepted by consumers, including satisfying nicotine dose, economic feasibility, and minimal unintended consequences.

Conventional smoking cessation approaches require nicotine addicted smokers to abstain from tobacco and nicotine entirely. Many smokers on the continent are unable – or at least unwilling – to achieve this goal, and so they continue smoking in the face of impending adverse health consequences. In effect, the status quo in smoking cessation presents smokers with just two unpleasant alternatives: quit or suffer the harmful effects of continuing smoking.

Tobacco harm reduction products, such as tobacco-free nicotine pouches, are quickly proving to be the most effective and safest alternatives for smokers who want to switch from cigarettes, but who want to continue enjoying nicotine or who are struggling to quit altogether.

Oral nicotine pouches are similar in appearance to an established form of smokeless tobacco product commonly used in Scandinavia called ‘snus’. The nicotine pouch products are placed between the upper lip and gum. The nicotine pouches are different to Swedish-style snus in that there is no tobacco in them.

Containing zero tobacco, the composition of oral nicotine pouches suggests that they should have among the lowest risk profiles of available alternative nicotine products. They are close to that of medically licensed nicotine replacement therapies (NRT). The fact is that oral nicotine pouches do not require combustion (no emissions), and contain no tobacco or the thousands of chemicals present in cigarette smoke (reduced exposure). The proven success of these products shows that tobacco control should no longer simply follow the ‘quit or die’ approach, which is so obviously failing in Africa.

Sweden, where smoke-free Swedish snus has displaced cigarettes, reports the lowest smoking rates in Europe, while the ratio of Swedish men suffering tobacco-induced cancers is less than half that of the EU average. Furthermore, Sweden has the lowest incidence of tobacco-related diseases in the European Union. These statistics from Sweden may be the most pertinent for Africa, where there is a tradition of using oral stimulants and where the consumption of smokeless tobacco is already the second-highest in the world.

Of all the potentially reduced risk products, oral nicotine products are the most affordable safer nicotine alternatives in Africa. Significant disparities in health outcomes around the world are driven by unequal access to essential health products. Affordability is usually the main culprit when it comes to smoking cessation in Africa. Pricing smokers out of safer alternatives is a severe misstep and will cost lives.

Most scientists agree that complete tobacco cessation is the best outcome for smokers, and any efforts to make available safer products need to be part of a comprehensive tobacco control strategy aimed at minimizing tobacco use through cessation and prevention.

By Joseph Magero

Chair: Campaign for Safer Alternatives