The session dedicated to African countries’ experience on Tobacco Harm Reduction was chaired by Dr Fares Mili, MD, CTTS, NCTTP, a specialist in addiction behaviours and President of the NGO “Societé Tunisienne de Tabacologie et des comportements d’addiction” and Prof. Solomon Tshimong Rataemane, head of the Department of Psychiatry at the University of Limpopo, South Africa.
Dr Mili opened the session by setting the scene for the discussion on reducing the smoking prevalence in Africa using Tobacco Harm Reduction (THR) strategy. As an introduction he stated that the World Health Organization’s (WHO’s) tobacco elimination programmes have not yet been able to reduce the smoking prevalence among African countries. Therefore, alternative opportunities are necessary to achieve smoking cessation in Africa. Prof. Rataemane, in his introduction, conveyed the need for behavioural change of Africans towards THR. He also expressed his thoughts on the current failure to understand the biological effects of nicotine on the human brain.
Dr Kgosi Letlape pointed out that even though the smoking prevalence has rendered for most nations, there are currently more smokers compared to 1999, as the prevalence has increased from 990 million to 1.1 billion users from 1999 to 2021 respectively (with population growth attributing to this). In 2005, the WHO Framework Convention on Tobacco Control (WHO FCTC) was the first treaty negotiated under the auspices of the WHO. The framework focused on combustible cigarettes and so did the prescribed MPOWER regimes, which were strategies adopted to fight the global tobacco epidemic. Most countries have seen a reduction in the prevalence of smoking including South Africa. However, in South Africa there are still 7 million combustible tobacco users.
The speaker added that there are many alternatives to combustible tobacco products, for example, Snus. Even though the WHO FCTC banned Snus globally, it is a legal product highly used for THR in Sweden. Sweden has obtained ‘big data’ regarding its benefits and is the only country that has adopted Endgame, a smoking prevalence rate below 5%. Dr Letlape concluded that the WHO FCTC is great for combustible tobacco products but inadequate for THR, stressing the need to advocate for regulations that are appropriate.
Dr Imane Kendili, President of the Moroccan Association of Addictive Medicine and associated Pathologies, then discussed the issue of tobacco addicts with psychiatric comorbidities from the Moroccan perspective. The speaker stated that there is a strong association of tobacco and depression. This is due to the dopamine and serotine pathways that lead to addiction. Smoking nicotine increases the rate of dopamine creating pleasure, and decrease serotonin, which increases anxiety and depression. This makes it harder for clinicians to understand whether depression is caused by withdrawal symptoms or actual depression.
Through Dr Kendili’s experience working in a small private clinic in Morocco, she suggested the need for further intensive treatments, longer duration of counselling and medication, higher dosing or combination therapy, relapse management and prevention, and increasing attention for opportunities in treatment cycles. The speaker concluded that these would allow clinicians to better understand whether smoking tobacco products lead to mental illnesses or whether it is vice versa.
The last speaker, Dr Uta Ouali, senior psychiatrist at the Razi Hospital La Manouba in Tunisia, acknowledged the need for a unified harm reduction approach to address the specificities of tobacco and other substance users. The speaker stated that first, smoking rates are 2-4 times higher for individuals that use other substances, second, lower cessation rates are associated with alcohol use disorder, and third, that cigarettes smoking increases the likelihood of substance use disorder (SUD) relapse.
Dr Ouali then discussed possible neurobiological modifications caused by repeated substance use. For example, reward system dysregulation, stress system overactivation and prefrontal cortex impairment. These factors impact the chances for individuals to quit smoking. The most frequent substances used with cigarettes are alcohol and cannabis. Tobacco and cannabis share common environmental factors and smoking cues that may contribute to sustained use. Alcohol and tobacco use increase the craving for one another suggesting underlying biological and physiological mechanisms.
To overcome these issues, the speaker advocated the need for unified harm reduction strategies. Both SUD and tobacco addicted patients should benefit from THR products including Snus, heated tobacco products and e-cigarettes. The speaker concluded that a unified approach could be an effective way to reduce the associated risk to both types of addiction and that partial substitution in general is ineffective, therefore, substitution must be a completed and sustained process to reduce tobacco harm.
Dr Letlape closed the discussion panel by summarizing the possible issues in relation to the consumer perspective of alternative tobacco products. The speaker stressed the importance of consumer access to credible information for individuals to make their own informed choices, and that governments should ensure availability and accessibility of all alternative tobacco products for THR.