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Tobacco Control Policy in Low- and Middle-Income Countries: The Case of India and South Africa

Drs. Surender Kashyap and Lekan Ayo-Yusuf discuss how stronger enforcement and collaboration are key to reducing the global burden of lung cancer in countries where tobacco-related deaths remain high.

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By

Surender Kashyap, MBBS, MD, Lekan Ayo-Yusuf, BDS, MSc, MPH, PhD

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Estimated Read Time:

6–9 minutes
Global Initiatives, Tobacco Control & Smoking Cessation

Tobacco-related deaths are predominantly concentrated in low- and middle-income countries (LMICs), where 80% of the estimated 8 million annual deaths, including those from lung cancer, occur.1

Surender Kashyap, MBBS, MD
Surender Kashyap, MBBS, MD

The most significant opportunity to address this global burden lies in LMICs’ ability to effectively implement evidence-based tobacco control policies recommended by the WHO Framework Convention on Tobacco Control (WHO FCTC), which currently includes 183 signatory nations.2

India, home to the largest share of the global population, and South Africa, one of the leading African economies and a key manufactured cigarette market, provide contrasting tobacco policy landscapes as BRICS members. The tobacco control measures and their impacts in these two countries highlight the potential for reducing lung cancer incidence and mortality through the WHO FCTC’s MPOWER strategies.

MPOWER was developed to reverse the global use of tobacco products, aiming to establish a monitoring (M) framework to track tobacco use and prevention policies worldwide.

Protecting (P) people from tobacco smoke by implementing and enforcing comprehensive smoke-free policies in public spaces, workplaces, and public transportation helps reduce exposure to harmful tobacco smoke.

Offering (O) assistance to quit tobacco use through support and resources such as counseling, nicotine replacement therapy, and quitlines significantly increases the chances of success for individuals trying to quit.

Additionally, warning (W) people about the dangers of tobacco products through effective health warnings on packaging and public awareness campaigns featuring clear and impactful messages deters individuals from starting to smoke and encourages current users to quit.

Enforcing (E) bans on tobacco advertising, promotion, and sponsorship has similar effects. Lastly, raising (R) taxes on tobacco helps reduce its affordability.3 India is not only the most populous country in the world, with more than 1.4 billion people, but it also ranks as the third-largest producer and the second-largest consumer of tobacco.4 An estimated 28.6% of adults (267 million individuals) aged 15 years and older (42.2% male and 14.2% female) consume tobacco products.4

Lung cancer is a major healthcare concern in India, accounting for an estimated 5.9% of new cancer cases and 8.1% of cancer-related deaths. Eighty percent of patients with lung cancer in India have a history of tobacco use,6 and tobacco smoking accounts for an estimated 930,000 deaths annually in India.5

Lekan Ayo-Yusuf, BDS, MSc, MPH, PhD
Lekan Ayo-Yusuf, BDS, MSc, MPH, PhD

In South Africa, an estimated 29.4% of adults 15 years and older are reported to be actively using all forms of tobacco products (41.7% male and 17.9% female).7,8 An estimated 31,000 deaths in South Africa are attributable to tobacco smoking.9

Tobacco smoking in South Africa is the dominant form of tobacco use, with prevalence estimated at 23% (Table 1). Lung cancer is the leading cause of cancer-related deaths, with an age-standardized incidence rate for lung cancer among males at 8.95 per 100,000 population.

However, unlike India, tobacco smoking remains the dominant form of tobacco use, with prevalence estimated at 23% compared to India’s 13% as of 2019 (Table 1).

Recognizing the substantial economic costs attributable to tobacco use, India has been proactive in formulating tobacco control policies to mitigate the public health burden. Key legislative measures introduced in the past two decades include the Cigarettes and Other Tobacco Products Act (COTPA) in 2003.10

This act mandates prominent health warnings on tobacco products and packaging, bans tobacco advertising, and prohibits smoking in public places. The National Tobacco Control Program (NTCP), enacted in 2007, aims to create awareness about the harmful effects of tobacco, support cessation services, and strengthen tobacco control laws.10 The WHO FCTC was endorsed in 2004.

E-cigarettes were banned in 2019 through an act of Parliament, and most tobacco products in India, including bidi—a special form of tobacco smoking prevalent in India—have the highest tax rate of 28%.

The National Tobacco Control Program (NTCP) is being implemented across 612 out of 766 (76.5%) districts in India.10 The NTCP has facilitated the execution of the MPOWER strategy and the m-Cessation Program, playing a crucial role in enforcing tobacco control under the Cigarettes and Other Tobacco Products Act (COTPA) and in line with the provisions of the WHO FCTC.

The establishment of tobacco control centers has aided users in quitting tobacco; it has also created awareness of tobacco cessation and provided training to those involved in tobacco cessation activities.10 A national quitline supports tobacco control centers. Additionally, yoga, which originated in India, may act as a complementary therapy for smoking cessation by involving breathing exercises and meditation.11

These tobacco control measures have positively impacted reducing tobacco consumption in India, as evidenced by the Global Adult Tobacco Surveys, which show a reduction in tobacco use from 38.1% in 2010 to 27.2% in 2020.12 Furthermore, lung, trachea, and bronchus cancer incidence reduced from 6.6 cases per 100,000 individuals in 2008 to 5.8 per 100,000 in 2022.13

Although, like India, South Africa ratified the WHO FCTC in 2005, it has made less progress in aligning its tobacco control laws with the WHO FCTC provisions (Table 1). South Africa, whose law in 1995 was seen as a global benchmark for comprehensive tobacco control, has not updated this law to be WHO FCTC-compliant.

This has left loopholes, allowing e-cigarettes and other new tobacco and nicotine products to remain unregulated and grow in use, without any significant reduction in smoking prevalence.14

Although the cigarette excise tax incidence is currently 52% of the cigarette price, the lack of enforcement of border controls, with the complicity of the tobacco industry, has allowed illicit cigarettes to rise to about 58% of the cigarette market.15

Similarly, the current law allows for designated smoking areas, and no graphic warning labels have been introduced, with only text warnings covering 20% of the cigarette pack (Table 1).

The result of these loopholes is that tobacco smoking in South Africa has not significantly reduced in recent times, with tobacco smoking prevalence estimated at 21.6% in 2010 and 20.3% in 2020.8 Similarly, the incidence rate of lung, trachea, and bronchus cancer of 18.1 per 100,000 in 2022 did not significantly change compared to an incidence rate of 18.2 per 100,000 reported in 2008.13

South Africa has proposed a new law that is WHO FCTC-compliant and aims to regulate new and emerging tobacco and nicotine products. It is currently being processed by the nation’s parliament.14

However, there has been significant opposition to the proposed law from the tobacco industry, which, in addition to well-known tactics of interfering with the policy process,16 has been recently accused of paying members of the public to oppose the law during public consultation.17

Despite progress in India, several challenges impede the effective implementation of tobacco control policies. These challenges include enforcement issues, socio-cultural factors, economic interests, gaps in awareness, healthcare infrastructure, and advocacy issues.

Addressing these challenges in South Africa and India and leveraging the opportunities in these countries to reduce the burden of lung cancer will require a multifaceted approach. This includes strengthening law enforcement, community engagement, and ensuring accessible smoking cessation support. The public support of the bill before the South African Parliament by international organizations, such as the IASLC, will be as important as its members partnering with researchers in South Africa and India. These partnerships will help build capacity for research and practice in effective tobacco use cessation, including for those already diagnosed with lung cancer.

References

About the Authors

Surender Kashyap, MBBS, MD

Surender Kashyap, MBBS, MD

Vice Chancellor, Atal Medical & Research University, H.P., India

Lekan Ayo-Yusuf, BDS, MSc, MPH, PhD

Lekan Ayo-Yusuf, BDS, MSc, MPH, PhD

Africa Centre for Tobacco Industry Monitoring and Policy Research, Head of the School of Health Systems and Public Health, University of Pretoria

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