An unfair fight The four tobacco giants (British American Tobacco, Philip Morris International, Imperial Tobacco, and Japan Tobacco International) spare no expense in their efforts to open up new markets. In this respect, Anna Gilmore has shown that communities in developing countries are exposed to 81 times more tobacco ads than those in developed countries.
Furthermore, at the end of 2015, a British documentary revealed that British American Tobacco was guilty of large-scale corruption in Eastern Africa, bribing politicians and civil society to oppose tax increases, among other things. Until recently, in Senegal, Philip Morris funded sporting events and parties at bars, distributed t-shirts, etc. And in many countries, industry representatives hand out cigarettes by the shovelful to 13 to 15-year-olds. More subtly, cigarette companies have mastered the art of supporting noble causes. Funding medical equipment, supporting children's education, improving access to clean water: they rely on "social and economic responsibility" to improve their image. "Recently, the industry provided financing for a group of 1,000 women vegetable farmers in Dakar,"explains Oumar Ndao. But there is hope. "Despite the intense lobbying and the misconduct, which make any action incredibly difficult, huge efforts are being made in Africa to strengthen tobacco control," says Anna Gilmore. With its legislation (even though it is still working on enforcing it), Senegal is a model on the continent. And the CRES team's determination has played a big part in that. In 2014, the Consortium also succeeded in passing an anti-tobacco statement in the 15 member countries of the Economic Community of West African States (ECOWAS) and the West African Economic and Monetary Union (WAEMU). The idea? Standardizing—and increasing(!)—taxes on tobacco throughout the region. "It's not easy to get 15 countries on the same page! Especially since Internet access is patchy in some places and the Ebola crisis prevented us from holding meetings," says Nafissatou Baldé. "The advantage for us is that we can still curb the market, unlike the markets that are more established, like those in Asia," she says. But there is still a long road ahead to ensure that this statement doesn't fall dead in the water. In countries struggling with alarming rates of infectious diseases, malnutrition and often unstable political situations, the chronic illnesses caused by smoking seem less urgent in the eyes of decision-makers. "Poor countries are 'short-termists,'" laments Oumar Ndao. Preventing a health crisis Nevertheless, tobacco use is a ticking time bomb. According to the WHO, by 2030, 80% of deaths caused by tobacco will occur in low- or middle-income countries. "Here, the health systems are not equipped to deal with chronic illness. It is estimated that, for every 10 people who require chemotherapy, only three will be able to receive it," explains professor Diagne. The poor are obviously the first to suffer. "In Senegal, patients are responsible for covering all of the costs, from consultation to treatment. Often, a cancer diagnosis is never made, because the patient cannot afford the tests. They request a sedative for the pain, and you never see them again," says Dr Ulrich Combila, a respirologist at the *Centre Hospitalier National Universitaire Fann-Dakar*. [image: A Senegalese man smoking] In a 700-page report released at the start of 2017, the WHO estimated that approximately 226 million smokers live in poverty. It is for their protection, first and foremost, that tax measures must be put in place, states the organization, even if some fear that this may add insult to injury. "The people who smoke the most already can't afford to. The degree of addiction is so high that, no matter what the price, they will pay it!" fears Combila, pointing out that the population must also be educated about the dangers of smoking, and that those already addicted must be helped to quit. In Médina, Modou enters a small cinder-block structure, with only a curtain for a door, and introduces Jim, an old friend with a toothless grin. It is after 10 a.m., he hasn't even had his breakfast yet, and he lights an umpteenth cigarette. When asked how long he has been a smoker, he laughs. "Since forever! But it's okay, I still have a little breath in me," he replies. Even if a pack costs 2,000 CFA francs [$4.35], I would still buy it!" No doubt the tobacco industry has a few good years ahead of it yet Africa needs statistics *More than ever before, in the era of "alternative facts", researchers need evidence, figures, and statistics to rely on. But such data are sorely lacking in Africa. * "Except in South Africa, there is a general lack of national data. The majority of countries do not conduct regular surveys of their citizens, outside of schools and hospitals," explains Catherine Kyobutungi, an epidemiologist and Director of Research at the African Population and Health Research Center <http://aphrc.org/> (APHRC), in Nairobi, Kenya. This non-profit organization, which receives funding from IDRC, conducts numerous studies on the continent (mainly in health and education), and advocates for authorities to rely on scientific evidence to make decisions. This is also the goal of the CRES in Dakar, which has just launched a survey to assess the health costs associated with tobacco use at 15 hospitals in Senegal (see our report entitled *Smoking: Africa Fights Back* <http://www.quebecscience.qc.ca/reportage_qs/Tabagisme-Afrique-contre-attaque>). "We are going to document cardiovascular and respiratory illnesses, as well as cases of lung cancer and laryngeal cancer, collect data on patients' tobacco use, and assess the direct costs (medication, consultations, staff salaries, tests) and indirect costs (lost wages, premature death)," explains Papa Yona Mané, an economist and project officer at CRES. It's an arduous task, since the hospitals don't have computerized records. The data will have to be collected manually over a period of three months, with the help of two doctors per hospital, using paper questionnaires. We have no choice, if we want to convince the government that smoking comes with huge costs. "The 'Achilles' heel' of the war on tobacco in Africa is the lack of statistics: we hardly have any figures to show," says Oumar Ndao, of Senegal's Ministry of Health and Social Action. Indeed, even official statistics, whether from governments, the World Bank or the WHO, should be taken with a grain of salt. "More often than not, they are extrapolations made from partial data. For example, if they have figures on tobacco use in Kenya, the WHO will propose estimates for Tanzania, Uganda, etc.," says Kyobutungi. Besides being a roadblock to improving governance, the lack of statistics hinders assessment of a population's degree of poverty, health status and access to basic services, and hinders achievement of international development goals. *The original French version of this article was originally published in the June 2017 edition of the magazine Québec Science <http://www.quebecscience.qc.ca/reportage_qs/Tabagisme-Afrique-contre-attaque>.* *Photo credit: Sylvain Cherkaoui*
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