Twenty-year-old Thuso lives in a small rural farming village in Kgalagadi South about 500 kilometres outside of Botswana’s capital city of Gaborone. It has a population of about 30,000 people. Only one in five households have access to flush toilets and less than half use electricity to light their homes.
Thuso is not employed but he makes some money with “on and off” part-time jobs. Despite this, he smokes a pack of cigarettes a day. And on a good day – by his own admission – he can drink two cases of beer.
His girlfriend Lindah – the mother of his two-year-old child – is also unemployed. She uses snuff three to four times a day. It’s a habit she picked up since she was 12. And her drinking patterns are much the same as Thuso’s.
Both realise that drinking too much could harm them. They have heard about the dangers of alcohol from messages on radio, at school, teachings at community gatherings and even from some family members. But neither have ever really heard that tobacco use could be harmful. In fact snuff was suggested for Lindah by a family member as remedy for her frequent nose bleeds as a child.
Thuso and Lindah are not alone. Across the region’s villages smoking and drinking patterns mirror those of Thuso and Lindah.
I was part of a Ministry of Health and Wellness team that visited the region to talk about living healthily and understanding what challenges people faced doing so. We met with health providers, community members and leaders, and conducted screenings for tobacco and harmful alcohol use, blood pressure, diabetes, obesity, and cervical cancer. Our visit coincided with a debate in Botswana’s Parliament about a new law, the National Tobacco Control Bill.
We found that in each village drinking and smoking rates were much higher than the average in the country. Furthermore, there was more pronounced use of smokeless tobacco such as sniffing or chewing snuff, predominantly by women.
This shows us that there are differences in the smoking patterns of rural and urban communities. Unless these are recognised and included in the in-country tobacco control interventions, efforts to reduce tobacco use will fail.
These were not good signs. Globally, tobacco is the leading preventable cause of death. According to the World Health Organisation, currently one billion people smoke and about 6 million die each year due to the effects of tobacco. It’s also among the four major risk factors for non-communicable diseases.
On the continent these diseases have become a major reason for premature deaths. And it’s estimated that there will be about 3.9 million deaths from non-communicable diseases in Africa by 2020.
This is against a backdrop of increasing smoking rates on the continent where about 14% of men and 2% of women smoke. This rising trend is seen only in Africa and the Eastern Mediterranean region, while all other regions in he world are experiencing declines in tobacco use.
A vulnerable choice?
Tobacco control efforts in Africa have centred on the rising smoking rates among middle-class urban communities. Messages are not in indigenous languages and are primarily distributed through commercial media.
Research shows that tobacco use is more popular in urban areas compared to rural areas. But the patterns of tobacco use in rural Botswana tell a different story. There are pockets of the population where rates of tobacco use are far higher. While the national average sits at 18% in Botswana, in Kgalaladi South it jumps to 29%.
If passed, the bill being considered by Botswana’s parliament will mark a milestone in the country moving towards fully implementing recommendations by the World Health Organisation. Botswana signed up to them in 2005 and to date has established a Tobacco levy, restricted smoking in public venues (designated smoking areas) and has outlawed direct marketing of tobacco products such as through TV, radio and other media.
The bill would outlaw smoking in all indoor public places and the sale of tobacco to individuals younger than 21. It would further restrict marketing of tobacco products (including indirect advertising) and mandate plain packaging, thus enacting regulatory and policy interventions that have been shown by studies to reduce tobacco use.
The bill also includes strategies to reduce use of smokeless tobacco, which affects key populations such as in Kgalagadi South.
But the bill won’t be enough on its own. Significant tobacco use takes place in people’s private homes, and ‘passed down’ at an early age from family members who have been using tobacco. Peer pressure significantly affects whether an adolescent will use tobacco, independent of the influence of advertising.
In an analysis of Botswana’s population based national survey (STEPS) on non-communicable disease risk factors that was conducted in 2014, peer pressure was cited as reasons for tobacco use among 20.3% of daily users. We need to find more effective ways to raise awareness and change mindsets of families, of peers, of communities to reduce social acceptability of tobacco use.
In poor, remote communities such as in Kgalagadi South, tobacco is not a ‘new’ trend. It is a slow brewing problem that has been present since colonial times.
In some communities in Botswana, smoking has been seen as a symbol of wealth. Tobacco was once a form of currency. As a result, those growing up in these communities begin to see the practice as not only normal but aspirational.
These traditional beliefs and lack of reach by conventional media makes addressing tobacco use more challenging.
To reach marginalised communities like in Kgalagadi South, public health messages must take into account everyone who is affected. This means messages need to take into account those whose first language may not be the official language, or who may have less interaction with conventional media.
Beyond having the information, interventions are needed that address culturally entrenched practices and beliefs through grassroots efforts that involve community leaders and school based programmes that impart life skills and prevent regular tobacco use at an early age. Tobacco cessation may sometime require pharmacological treatment for heavy users; we need to ensure that this is available equitable. This is the way to break the vicious patterns of tobacco use.
If these do not take place, Botswana – and many other countries like it – will fail those who are the most vulnerable.