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Ethiopia is one of the few countries that evaded the global tobacco plague; yet, with aggressive measures at many levels, it can maintain its low smoking prevalence, and even reduce it further. But that is less likely to happen if its ruthlessly ambitious monopoly believes “in creating a more ergonomic workspace to improve” its business

Dr. Frank Ashall, Special to Addis Standard

In 2008 out of 135 countries surveyed the World Health Organization (WHO) ranked Ethiopia as the country with the lowest smoking prevalence globally. A more recent survey of 187 countries placed Ethiopia as one of only six countries with a smoking prevalence below 5% among those over 15 years old. And a 2012 study by the World Lung Foundation (WLF) revealed an adult Ethiopian smokes a mere 62 cigarettes on average per year. These are statistics to be proud of, but there is evidence that smoking rate is increasing alarmingly in Ethiopia, as is the case in many other African countries.

A recent study of adolescents aged 13 to 19 attending schools in Jimma and Hawassa towns, some 350km West and 300Km south of the capital Addis Abeba respectively, found that one in six adolescents is an active smoker, including over a quarter of males and a sixth of females surveyed. Sixty percent of these adolescents, many of them non-smokers, were exposed frequently to second-hand smoke.
Smoking rates vary significantly across Ethiopia. In some areas the number of men smokers is way higher than the reported national prevalence of smoking in Ethiopian men of less than 10%; and it is higher than the prevalence of smoking for men in many other countries.

The fact that the National Tobacco Enterprise (NTE), Ethiopia’s tobacco monopoly increased its production of cigarettes from 4 billion a year to 6 billion a year recently also implies that smoking is worsening among Ethiopians. To achieve this feat, the company acquired a new machine worth 145 million ETB that can produce an astonishing 12,000 cigarettes 500 packets per minute. Its products exclusively target domestic market.

On its web site, NTE states that its five years strategic plan “aims (sic) and it’s diligently working towards a “greater market expansion,” a plan that involves developing more tobacco farms and upgrading existing ones. In 2014, NTE’s profit before tax stood at 377.4 million ETB, up by 13.9% compared to its profit the previous year. Still, NTE’s official vision is “To be a cigarettes (sic) exporter subsequent to the full satisfaction of the national demand.”

A cursory look into several tobacco facts published in medical research journals, including documents by WHO and CDC, suggest tobacco is the most common cause of preventable human deaths globally, causing one out of every ten deaths, and this is expected to increase to one out of every six deaths by 2030. Over a half of all smokers will die from their habit. This amounts to 6 million tobacco-related deaths yearly across the world. Of these, 600,000 deaths occur to non-smokers who are exposed to the fumes of other smokers, and many of these passive smokers are women and children.

But insensible of the impact of tobacco on human health, NTE’s web site mentions the word “disease” a mere two times; both referring to concerns about diseases that affect tobacco plants.

Contrary to what many people might think, 80% of all smokers and 80% of all tobacco-related deaths occur in low- and middle-income countries, a category that Ethiopia is in. The trend is that smoking prevalence is falling in high-income countries where tobacco legislation is being enforced, whereas cigarette smoking is increasing by over 3% per year in low- and middle-income countries. Tobacco companies, sensing reduced revenues in countries where tobacco control is getting stronger, have switched their focus on marketing their products to developing countries, an act that saw Sub-Saharan Africa in the early stages of a tobacco epidemic.

Illegal but commonplace

In Ethiopia publicizing tobacco is illegal as clearly stated in the Federal Negarit Gazeta Advertisement Proclamation (Proclamation No. 759/2012) dated August 2012, part six, section 25, item 1 (i), that: “advertisement of cigarette or other tobacco products…….through the use of any means of dissemination shall be prohibited.”

However sturdy plastic posters, presumably designed to withstand the downpours of the rainy season, have littered many parts of the capital, including residential areas, promoting the British American Tobacco’s Rothmans cigarettes. Their slogans read: “DISCOVER OUR LEGACY: TRUE TOBACCO TASTE.”

Ironically, on January 21, 2014, around the time the Rothmans cigarettes posters were circulating in Addis Abeba, the Ethiopian House of People’s Representatives (HPR) ratified the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) treaty.

The WHO FCTC document provides guidelines for governments to regulate such issues as tobacco advertising, promotion and sponsorship, sales of single cigarettes, sales to minors, protecting people from passive smoking, tobacco prices and taxes, health warnings on tobacco packs, reporting of tobacco constituents such as additives and nicotine levels, illicit trade of tobacco products and economically viable alternatives to tobacco.

The treaty went into force in Ethiopia on June 23, 2014. This was presumably a landmark development in Ethiopia’s fight against tobacco-related diseases. Subsequently the Rothmans cigarette advertisement posters were pulled down by the authorities. Ethiopia’s ratification of the WHO FCTC tobacco treaty left just a handful of countries that have still not ratified the treaty – 180 countries have so far ratified the treaty. Remarkably, the USA is one of the countries that have yet to ratify the treaty.

But enforcing the treaty is another matter.

Mohammed Kedir, (name changed), is a shopkeeper off Mickey LeLand Avenue (the busiest clubbing district of Addis Abeba commonly known as Chechnya). In an interview with Addis Standard Mohammed admitted selling single cigarette pieces to his customers, including minors, a trend prevalent throughout the country. “I didn’t know that was prohibited,” Mohammed said. “Nobody told me.” When confronted why he sells single cigarette pieces to minors, Mohammed answers: “Some of them are running someone else’s errand. They are buying it for grownups.” But he admits some minors also “smoke, especially the street children”.

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But contrary to the reality on the ground NTE claims that its core value, “dictates that tobacco should only be marketed to adult smokers. We also believe that adults, who have chosen to smoke, should be able to receive information about what they buy.” But until recently information alarming customers of tobacco related hazards that are visibly displayed in many cigarette brands worldwide were almost illegible on all of the five varieties of the NTE products: Nyala Premium, Nyala, Delight, Elleni and Gisilla. And in many parts of Ethiopia, street vendors, including children, are openly selling cigarettes.

No adult choice

 
The notion that tobacco is an “adult choice” is a myth. Over 85% of adult long-term smokers began smoking when they were younger than twenty: it was during their teen years and earlier that most of smokers become addicted to tobacco; half of teens who smoke go on to become life-time smokers. Globally, about one out of every five teens smoke, and every day between 80,000 and 100,000 children start smoking. Most of them are in low- to middle-income countries.

 
However, these are facts that the NTE doesn’t seem to be concerned as its ambitious expansion and modernization programs continued unabated. In addition to producing its own brands, NTE’s monopoly over the business means it is also importing well known global brands such as Rothman of the British America Tobacco (BAT), and Marlboro of Philip Morris International (PMI); it also has the authority to issue permits for the importation of other global brands.

On its web site, BAT states that it is “widely accepted that nicotine is not the cause of smoking-related diseases”, a statement heavily disputed and dubbed as an utterly inaccurate by seasoned health professionals and medical journals. According to several medical research works, most smokers (over 70%) want to quit smoking, but because of the highly addictive nature of nicotine, less than 10% manage to quit permanently with their first attempt, and even most smokers do not quit after multiple attempts. A field research trip in several rural towns in Ethiopia shows that the habit of smoking is common among men; success in getting away from it is not. Several of them were desperate to quit smoking, even going to the extent of dipping their cigarettes in petrol to try and quit. This, some said, made them feel sick and stopped them smoking for a few days, but the addiction was so strong that they reverted back to the habit quickly. But this too eludes the NTE, which imports BAT’s Rothmans with “special arrangement.”

Furthermore, in March 2015 representatives of BAT and five selected wholesalers have met with NTE Managing Director Gizachew Hagos to “alleviate the current Rothmans cigarette sales problem prevailing due to the unstructured market of the country.” BAT complained of the “declining purchasing pattern of Rothmans by NTE’s wholesalers.” As a result, following the meeting NTE accepted “BAT’s plan to make use of few selected wholesalers to act as Distributors.” Five wholesalers were subsequently chosen “based on their financial capacity, rich experience in the field, and wide consumer reach sales outlets throughout the country,” a statement from NTE reveals. Each of the wholesalers will be able to buy “a minimum of 50 master cases weekly.” “This marketing approach is believed to help sustain Rothmans volume in a consistent manner without price war, speculation and hoarding in the market.”
The public sphere nexus

In 2014, Ethiopian lawmakers have unanimously passed a law prohibiting smoking in public. Following the ratification of the law, at the beginning of 2015, Meqelle, the Seat of the Tigray Regional State in the north, became the first city to ban smoking in public places. Anyone who trespasses the ban will be subject to a fine of 1000 ETB. Meanwhile in the capital Addis Abeba, although “No Smoking” posters can be seen hanging on the walls of various cafes and restaurants and are generally respected, smoking in public is a common practice.

It is also a common trend that in many rural parts of Ethiopia, men smoke in public places and at their homes, which often consist of small, poorly ventilated rooms. Involuntarily, they expose their children and wives to cigarette smoke and consequently to smoking-related diseases.

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This is an alarming trend in a country which, according to WHO, ranks “third in Africa and eighth among the 22 highest tuberculosis (TB) burdened countries in the world.” It is a well established medical fact that tobacco use has a significant detrimental impact on tuberculosis. The risk of a smoker contracting tuberculosis is twice that of a non-smoker, presumably because smoking lowers the ability of a person’s airways and immune system to fight off infection. Smoking also doubles the risk that a person who has tuberculosis will die from the disease. There is similar data suggesting that smokers are also more likely to contract HIV, more likely to be sick from HIV and more likely to progress to full blown AIDS than those who do not smoke.

 
The Ethiopian Food, Medicine and Healthcare Administration and Control Authority (EFMHACA) is the authority mandated to implement the WHO FCTC tobacco treaty regulations. Accordingly, EFMHACA released its Tobacco Control Directive in March of this year (ironically the same month when worried BAT representatives were meeting their counterparts at NTE). The directive prohibits smoking in indoor public places, including restaurants, hotels, bars, nightclubs, cafes, factories and shopping malls, public work places, health and education institutions, on public transport, in prisons, police stations and in government offices.

Encouragingly, smoking in outdoor areas of university and hospital campuses is now allowed only in areas specifically designated for smoking. But the city administration is yet to follow suit in implementing these regulations in a wider scale.

Meanwhile, under pressure from several directions the NTE has taken a few important steps to implement the WHO FCTC regulations in Ethiopia. Nyala cigarette packs, for the first time, now display clearly visible health warnings on both front and back of the packs, in compliance with WHO FCTC regulations. Medications that help smokers to quit have also appeared in the List of Medicines for Ethiopia, produced by the EFMHACA.

But other highly determinant factors, such as nationwide awareness campaign on the dangers of smoking, remained unaddressed.

Taxes and Illicit brands

The issue of raising tobacco taxes and controlling illicit brands are some of the measures Ethiopian policy makers are shying away from. Both have been adopted by many countries in the world as the most effective way of reducing smoking prevalence, especially in children and youth. Many countries have achieved substantial reductions in smoking rates through tax increases. Several researches indicate that for every 10% increase in price of cigarettes due to taxes, there is a 5% drop in tobacco consumption. However, in the WHO Report on the Global Tobacco Epidemic 2015: Raising Taxes on Tobacco, Ethiopia was one of only 15 countries that had less than a 20% share of total taxes of retail price of its most widely sold cigarette brand Nyala.

The retail price of the most sold brand, Nyala, in pack of twenty cigarettes, is 12.00 ETB. The total taxation of this brand is 50.3 per cent of the retail price. The annual tax revenues from tobacco products for the year 2011 (including excise tax, value added tax and import duties) totaled a little more than 639 million ETB.

But tobacco companies often complain that taxation, by raising the price of cigarettes, encourages illicit tobacco trade. Illicit trade in tobacco, usually from smuggling tobacco or from counterfeit cigarettes, is undoubtedly a huge problem in Ethiopia.

About 10% of the global tobacco market involves illicit trade. The reality, though, is that illicit tobacco trade occurs even more in countries where tobacco prices are low compared to those where prices are high. Experts argue tobacco smuggling is not so much due to high cigarette taxes and prices as it is due to the existence of organized criminals, poor control of smuggling, weak enforcement of anti-smuggling laws, and corruption.

There is ample evidence, indeed, that numerous transnational tobacco companies actively supported and encouraged cigarette smuggling, including the smuggling of cigarettes into Ethiopia. In a document from the Legacy Tobacco Documents Library (a collection of millions of internal tobacco company documents that was made available to researchers as a result of litigation against tobacco companies in the USA in 1998), a report of a “Meeting of Committee of Directors” of British American Tobacco, held in 1968, included the following paragraph, under the heading, ‘ETHIOPIA’:

“Our brands are doing well on the domestic market, within the limitations imposed by the [National Tobacco] Monopoly, [now the NTE], but our share of transit business is unsatisfactory and steps were taken to rectify this including the release of BENSON AND HEDGES SPECIAL FILTER to transiturs … now the Monopoly has confirmed that it will not release this brand officially in the immediate future.”

Cigarettes released to the “transit” system were tax-free and often were illegally smuggled into a given country to be sold cheaply, especially if the cigarette brand was not officially accepted by that country.

The WHO has produced a new treaty, the WHO Protocol to Eliminate Illicit Trade in Tobacco Products, which helps countries tackle specifically the extensive problem of illegal tobacco practices. So far, only 54 countries have signed this treaty and only eight have ratified the treaty; Ethiopia is not one of them. It has been estimated that over 150,000 tobacco-related deaths are due to consumption of illegal tobacco products, mainly cigarettes.

Tobacco farms
As if the century-old tobacco assault on human health was not enough, child labor on tobacco farms the world over is rife. In Africa, tens of thousands of children, some as young as five, work as child laborers on tobacco farms, losing the chance of having a proper education and a decent childhood. It is a strong indicator of why children are paramount to the tobacco problem and why tobacco production needs to be regulated.

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NTE Officials isnpecting a tobacco farm in Robi

 

The NTE has four tobacco farms: Robi tobacco farm, located 225Km far from Addis Abeba in the Amhara Regional state; Billate, Hawassa and Wolyta farms located in the Southern Nation Nationalities and Peoples’ Regional state.

Tobacco farms, undeniably, can provide tax revenue and employment opportunities, and export profits, but accepting a trade-off between these benefits and the human suffering, loss of workforce and massive healthcare costs of tobacco-related diseases is the dilemma NTE finds itself in. Three African countries, Malawi, Zimbabwe and Tanzania, are among the top ten tobacco leaf producing countries in the world. Despite this, all three countries are among the poorest in the world.

Ethiopia is one of the few countries that evaded the global tobacco plague; yet, with aggressive measures at many levels, it can maintain its low smoking prevalence, and even reduce it further. But that will not happen with products solely targeting the local market and a ruthlessly ambitious monopoly which believes “in creating a more ergonomic workspace to improve our business by choosing the right manufacturing equipment to enhance our workers’ productivity” and a recent acquisition of a new machine for 145 million ETB that can produce an astonishing 12,000 cigarettes and 500 packets per minute. Unfortunately, that, according to NTE is “part of running a successful business [that] involves keeping up with technology”.


 
ED’s Note: Frank Ashall, B.A.(Oxon), M.D., D.Phil, is Associate Professor of Biochemistry in Addis Abeba University (AAU) Medical School.

Addis Standard’s Kalkidan Yibeltal contributed to this story.

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