Are cigarette alternatives the lesser evil?

This month the government has had to change course halfway through its current cancer control strategy, after evidence showed it is not working.

Alarmed by increasing cancer cases, 28,000 in 2011, the government had then launched the first five-year national cancer strategy with several key targets.

For example, the strategy promised to reduce smoking by 5 per cent, obesity by 2 per cent, while increasing fruit and vegetable intake by five per cent by 2016.

This did not happen with the plan succeeded by a similar one that would have run to 2022. But this has been unexpectedly replaced this month by a third, which runs to 2030.

Explaining the unusual development, Principal Secretary for Health Susan Mochache said despite those elaborate strategic plans, “cancer cases have continued to increase rapidly.”

Since 2011 the number of annual cancer cases has risen from 28,000 to 47,000 last year. Within the same period, obesity has also risen from about 15 per cent nationally to 28 per cent today. Only six per cent of Kenyans are consuming adequate fruits and vegetables.

“It is against this background that the Kenya Cancer Policy 2019-2030 has been developed,” said Ms Mochache in the new policy document. The ministry says the new strategy is based on an evaluation of the preceding cancer strategic plans, with their failure blamed on poor implementation.

This, it says, is particularly the case with poor enforcement of the Tobacco Control Act, 2007. Tobacco is blamed for about 8,100 annual deaths in the country.

Despite the control Act, the ministry estimates smoking in Kenya to have remained at about 13 per cent and on the rise in young adults.

“I am disappointed the law has not worked,” says Meshak Mbochi, a graphic designer whose brother was crushed by a bus as Nairobi City askaris chased him for smoking in public.

“I have since taken to e-cigarettes in the hope I can kick the habit,” Mbochi, also a smoker, told The Standard.

The Tobacco Act, the ministry says, has also had some unexpected consequences, including increased consumption of smokeless tobacco; such as snuff and chew products.

A recent survey by the Division of Non-Communicable Diseases, of the Health ministry reported an almost doubling in the use of smokeless tobacco - to four per cent - since the enactment of the tobacco law.

Oral nicotine pouches

The team also found a small but significant number of mainly urban Kenyans turning to e-cigarettes. This, the health officials say, is encouraging because use of e-cigarettes has been associated with tobacco cessation.

“While motivations for usage are not clear, tobacco cessation is associated with increased use of e-cigarettes,” says the survey in the journal BMC Public Health.

“It may be time to re-look the tobacco control strategy, especially whether some of the new products could reduce harm or increase cessation,” says Campaign for Safer Alternatives chair Joseph Magero.  

For example, in February the British American Tobacco (BAT) announced it was putting up a Sh2.5 billion factory in Nairobi for the manufacture of oral nicotine pouches.

These are marketed as a safer alternative to cigarettes, with reported capacity to help those who want to quit.

But Joel Shunza Gitali, the chairman of Kenya Tobacco Control Alliance, is having none of that, and says there is no adequate scientific data to show the smokeless pouches are a less risky alternative to cigarettes.

Two weeks ago, the US Federal Drug Agency (FDA), after going through more than 1 million scientific documents, allowed the tobacco company Philip Morris International (PMI) to market its ‘heat, not burn’ product called IQOS as a safer alternative to cigarettes.

IQOS heats tobacco rather than burning it, a process claimed to be less harmful than smoking conventional cigarettes.

“The FDA’s decision is consistent with earlier conclusions of other leading regulatory and scientific bodies, including in the UK, Germany, and the Netherlands, which have found that the product emits lower levels of harmful toxicants,” said Andre Calantzopoulos, the CEO at PMI.

The company, which plans to eventually eliminate cigarettes, says already 15 million people in 53 markets are using its heated tobacco products.

“Smokescreen,” says David Makumi, of the Kenya Network of Cancer Organisations. He says these are industry tactics to remain in business, though he agrees current tobacco control policies are not working.

Makumi largely blames this on government lethargy to fund tobacco control activities and failure to take a hardline stance against manufacturers.

But data shows this is hardly a Kenyan problem with the world unlikely to meet the UN Sustainable Development Goals (SDGs), targeting a 30 per cent reduction in tobacco use.

The World Health Organisation 2019 global report on tobacco use shows there were about 1.39 billion smokers globally in 2002. The number dropped to 1.35 billion in 2015 and is expected to stand at around 1.3 in 2025.

“The slow progress dictates we explore new approaches such as harm reduction where smokers are encouraged to use safer tobacco products,” suggests Magero. 

While not giving details the new cancer strategy says tobacco cessation and risk reduction will be key priority areas.