Vol. 2, No. 2
ugandahealthcom@yahoo.com
March 7, 2008
Tobacco Control Returns to the Public Agenda A new battle has begun over an old public health problem. On Tuesday, 3 March, public health advocates came to a UHCA workshop to unveil a new legislative proposal designed to reduce tobacco consumption in Uganda. The measure would outlaw the sale of tobacco products to children, allow sales only by licensed dealers, ban advertising and other tobacco promotional strategies and require tough new warning labels on tobacco products and at places where they are sold. The stakes are high: the World Health Organization projects that by 2030 some 30 million people will die each year from tobacco, and 70 percent of these deaths will occur in developing countries like Uganda. But enactment of the legislation is far from certain. The proposal faces likely opposition from powerful interests, including the tobacco industry, tobacco farmers and local officials in districts where tobacco is a mainstay of the economy. The national government’s response to the bill is uncertain too. Although Uganda signed the international Framework Convention on Tobacco Control calling for strong measures to reduce tobacco use five years ago, the government depends heavily on revenues tobacco sales. It is unclear whether it will stand behind measures that might threaten this revenue source.
Former Uganda Medical Association President Margaret Mungherera and reporters at UHCA’s Tobacco Control Workshop
Describing the obstacles anti-tobacco advocates face, Daniel Kalinaki, managing editor of the Daily Monitor, predicted that the success of the proposed tobacco controls will require “education and galvanizing a critical mass of people” behind them. Past tobacco-control efforts, he said, fell short because advocates took a “top-down approach,” relying on government mandates rather than creating a sense of “public ownership of the control agenda.” Public ownership, he said, must begin with knowledge. In this issue, we provide background and resources that will help you prepare for the coming debate. For copies of the draft legislation or PowerPoint presentations from the UHCA workshop, contact us at ugandahealthcom@yahoo.com
Covering Tobacco Tobacco and Health: Why tobacco controls are needed……………………….................Page 3 Key provisions of he proposed tobacco-control law………………………………………..Page 4 Tobacco Politics...................................................................................................................Page 5 Resources on Tobacco and Health……………………………………………………………..Page 6
Health Communication News… New Support for UHCA: We extend our deepest appreciation to four new partners who are helping the alliance expand our programs: •
The Health Communication Partnership (HCP), a project of the Johns Hopkins University Bloomberg School of Public Health, is working with UHCA to offer four regional workshops to train health journalists and public relations officers.
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The Population Reference Bureau, a non-government organization based in Washington, D.C., has enlisted UHCA to help it organize a series of workshops and study tours on reproductive health and unintended pregnancy.
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The United Nations Association of Uganda has agreed to provide UHCA an office at its headquarters in Ntinda, Ministers Village, Kampala.
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The International Center for Journalists, a non-government organization based in Washington, D.C., has donated a computer, slide projector and printer to UHCA. This is in addition to substantial support provided by Christopher Conte, a Knight International Health Journalism Fellow appointed and funded by ICFJ, who is now in his second year in Uganda.
World Tuberculosis Day. Tuberculosis continues to be a major public health problem globally, especially in Asia and Africa, says Dr. Francis Adatu-Engwau, Program Manager National TB & Leprosy Programme, Ministry of Health. In anticipation of World Tuberculosis Day on March 24, he notes that an estimated 9.2 million new tuberculosis cases and 1.6 million deaths occur annually around the world. Uganda is ranked the 15th among the 22 TB high burden countries in the world. In 2007, the country reported a total of 41,579 cases, of which 20,364 (49%) were infectious. The proportion of expected cases detected (Case Detection Rate-CDR) was 50.2%, well below the 70% global target. Only 75.5% of the 2006 cohort were successfully treated, below the 85% target. The Ministry, with the World Health Organization, the Tuberculosis Control Assistance Program (TCAP), the Uganda Program for Humanistic and Holistic Development (UPHOLD) and the German Leprosy and TB Relief Association (GLRA) have developed standardized training for health personnel and put in place a technical supervision program to ensure quality control in diagnostic units in 77 out of 80 districts. But challenges remain. According to Dr. Adatu-Engwau, laboratories have insufficient resources and high labour turnover. Districts have limited resources for TB control (all funds are lumped together within primary health care grants). The absence of a dedicated budget line at the district level leads to supply interruptions. And there are no funds for advocacy communication and social mobilization.
CALL FOR NOMINATIONS. AfriComNet is seeking nominations for the 3rd Annual Awards for Excellence in HIV and AIDS Strategic Communication in Africa. 1. Deadline for nominations: March 20, 2009 2. Eligibility: Individuals and organizations implementing HIV/AIDS strategies, campaigns and tools that advance the field of strategic communication and can be evaluated, adapted and applied as best practices. 3. Award categories: 1. Best mass media campaign, intervention or production. 2. Best folk media initiative. 3. Best multi-channel communication. 4. Best interpersonal/community-based communication. 5. Best HIV- or AIDS-related article, series or column. 4. Forms for nominations can be downloaded at AfriComNet from http://www.africomnet.org or can be requested by email at infodesk@africomnet.org
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Focus on Tobacco
Why Do We Need to Regulate Consumption?* Dr. Margaret Mungherera Consultant Psychiatrist Former President, Uganda Medical Association Tobacco contributes to numerous health problems: •
Oral Cavity: Gum Disease, Staining of teeth, bad breath (halitosis), tooth loss, white patches on lining of mouth (leucoplakia) and cancer of the lip, tongue, mouth and throat.
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Pulmonary System: Chronic Obstructive Pulmonary Disease (COPD), a permanent, incurable reduction of the pulmonary system capacity characterized by shortness of the breath, wheezing and persistent cough. There also is evidence that long exposure to carbon monoxide, one of many harmful ingredients in tobacco, damages the lung.
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Cardiovascular System: Increased chance of heart disease, stroke, artherosclerosis and peripheral vascular disease; Buerger’s Disease (inflammation and clotting of blood vessels in the hands and feet); increased ‘bad’ cholesterol.
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Infections: Smokers have 3-4 times greater risk of acquiring Tuberculosis than non-smokers; they also have increased rates of respiratory infections like colds and bronchitis.
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Cancer. Smoking is a risk factor for cancer of the respiratory tract, pancreas, kidney and ureters, colon, cervix, bladder, stomach, and blood or bone marrow (leukemia).
The average age of initiation is now below 10 years. Young people generally are not aware of the health risks. •
Reproductive health. Decreased fertility, miscarriages, low birth-weight babies
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Children. Second hand smoke causes ear disease, chest infections, Sudden Infant Death Syndrome (SIDS), pneumonias and bronchitis
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Nicotine addiction can occur as early as five months after a person starts smoking. When denied nicotine, most smokers become irritable, jittery, and have dry mouth, rapid heart beat, eventually sleeplessness and mild depression.
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Other psychological effects. Memory impairment, shrinkage of brain (brain atrophy) and increased risk of Alzheimer’s Dementia
Tobacco and health trends • • • • •
The number of people smoking in Uganda has increased 10 times since the 1960s; 25% of men and 3% women smoke in Uganda (Uganda Demographic Health Survey, 2001) The average age of initiation is now below 10 years (Global Youth Tobacco Survey, 2002). Among adolescents, 14.2% in Kampala and 33% in Arua districts are regular smokers (Uganda Youth Tobacco Survey). Young people are generally not aware of the health risks. Tobacco is a risk factor for 6 of the 8 leading causes of death. Most smokers want to quit but cannot because of they are addicted. Treatment of tobacco is too expensive. It costs approximately US $5,000 to treat one lung cancer patient for a year in the Uganda Cancer Institute.
*This is drawn from Dr. Mungherera’s PowerPoint presentation at the March 3 UHCA workshop on tobacco control. For the full slide show, send a request to ugandahealthcom@yahoo.com.
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Focus on Tobacco
Key Provisions of the Proposed Law* Gilbert Muyambi The Environmental Action Network (TEAN)
Tobacco Control Committee z z z
A Tobacco Control Committee chaired by the Ministry of Health with members from other ministries, departments and civil society would be established to implement the law. It would implement and harmonize tobacco control measures at all levels of government. The committee may recommend tax measures designed to increase the price of tobacco. All forms of tobacco advertising and sponsorship would be banned, as would free distribution of tobacco products.
Tobacco Packaging and Labeling z
z
All packets shall have health information about the product and its emissions, health hazards and effects that arise from the use of the tobacco product or its emissions. The information must be in large, clear, visible and legible language covering at least fifty percent or more of the principal display area of both sides of the package. It would have to be changed at regular intervals. No misleading descriptor – such as ‘light,’ ‘mild,’ ‘low tar’ – may be used to describe the toxic constituents of a tobacco product.
The National Environmental Management Authority lists Acute Respiratory Infections as the second leading cause of infant visits to health centers. One causes of ARI is exposure to tobacco smoke. Restrictions on the Sale, Supply and Use of Tobacco Products z z z z z
Sale of tobacco products can only be by licensed dealers and in certain places Dealers must display signs describing the dangers of consuming tobacco and explaining that it is illegal to sell tobacco products to people under 18 Sale of tobacco in vending machines, in self-service displays or over the Internet is prohibited. Cigarettes may not be sold singly or in packages of fewer than 20. Supply of tobacco products to children is prohibited.
Involuntary Exposure to Tobacco Smoke z
Smoking is prohibited in public places.
Protection of the Environment z z
The National Environment Management Authority would be empowered to monitor the use of chemicals in tobacco farming The government would be committed to create viable alternatives for tobacco growers.
*This is excerpted from Mr. Muyambi’s PowerPoint presentation at March 3 UHCA workshop on tobacco control. For the full slide show or a copy of the draft law, send a request to ugandahealthcom@yahoo.com.
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Focus on Tobacco
What will determine the fate of tobacco control legislation? A variety of forces are combining to make countries like Uganda focal points in the battle over tobacco. Even as global awareness about the dangers of smoking, including the harm done by second-hand smoke, is growing, falling profits in the west are making emerging economies more attractive to tobacco companies. At UHCA’s March 3 workshop on tobacco control, Daniel Kalinaki, managing editor of the Daily Monitor, cited factors that will help determine the outcome of the debate. One is British American Tobacco Uganda’s status as a major taxpayer (last year, it paid the government sh46 billion in taxes, an amount equal to 12% of the national health-sector budget). That affects not just national but regional politics as well. Kalinaki urged journalists to watch for political pressure from local authorities in tobacco-growing regions. He also noted that BATU’s status as a publicly-listed company means substantial numbers of investors who are concerned for its commercial success may resist measures designed to reduce consumption. Kalinaki also observed that the tobacco company’s corporate structure increases its leverage. BATU concentrates on growing tobacco in Uganda, while its cigarette manufacturing operations are mostly based in Kenya. As a result, it can rally manufacturing interests in Kenya to join domestic tobacco growers in this country to oppose Ugandan legislation.
Daniel Kalinaki
Offsetting these factors, however, is growing public awareness and concern about health. The outcome of the new tobacco debate may depend on whether control advocates can tap that awareness to mobilize the public to support their proposals. Previous efforts to reduce tobacco consumption have suffered in part because advocates relied on a “top-to-bottom approach that did not allow public ownership of the control agenda,” Kalinaki said. Will things be different this time? The key will be young people. “The battle is between public health campaigners and big tobacco to recruit young people,” Kalinaki said. His observation may explain provisions in the tobacco control bill that would prohibit tobacco advertising, ban the sale of tobacco products to people under age 18, and prevent the sale of cigarettes one at a time – that is, in a quantity that young people can afford.
“The battle is between public health campaigners and big tobacco to recruit young people.” The Daily Monitor editor stressed the need to increase public knowledge about tobacco and its role in the country’s economy and politics. UHCA believes tobacco’s economic impact on Uganda is one issue that needs to be explored further. While it is well known that BATU paid a lot of taxes last year, how much was spent by the public sector on curbing or managing tobacco related illnesses like TB and lung cancer? How many man hours of work were lost because some people were ill with these illnesses? Also, are the new tobacco-control proposals tailored to Uganda’s complex patterns of tobacco use? For example, the proposed legislation may reduce demand for processed tobacco but to what extent do Ugandans use unprocessed tobacco? And what specifically will be done to help farmers find viable alternatives to tobacco growing?
Stay involved: It’s going to get interesting!
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Focus on Tobacco
Resources Uganda-based Research: Tobacco use among high school students in Kampala, Uganda: questionnaire study. By Lillian Mpabulungi , Project Manager of Care Uganda and Lecturer, University of Malawi. http://www.ncbi.nlm.nih.gov/pubmed/14968459?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pub med.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum Tobacco use among high school students in Arua, Uganda. By same author as above. http://www.ncbi.nlm.nih.gov/pubmed/17083279?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pub med.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum Web resources: The Framework Convention on Tobacco Control: The international treaty to limit tobacco control, which commits countries to take steps to limit both the demand and supply of tobacco through measures ranging from higher taxes to labeling and packaging restrictions. http://www.who.int/fctc/en/ The World Health Organization Tobacco Free Initiative: http://www.who.int/tobacco/en/ . WHO launched this program in response to an “elaborate, well-financed, sophisticated and usually invisible” effort by tobacco companies to subvert tobacco control, writes Kenyan freelance writer Florence Macchio. http://www.dcp2.org/features/40/efforts-to-write-tobacco-control-laws-meetresistance-in-kenya, National Library of Medicine: “There’s no way around it. Smoking is bad for your health,” this U.S. government institution says. Its “Medline Plus” database explains the harm smoking does to “nearly every organ of the body,” from lung, heart and blood vessel disease to strokes, cataracts, and sudden infant death syndrome. http://www.nlm.nih.gov/medlineplus/smoking.html. NLM also addresses smokeless tobacco: http://www.nlm.nih.gov/medlineplus/smokelesstobacco.html World Bank: Well over 100 studies have shown that increasing taxes on leads to significant reductions in cigarette smoking and other tobacco uses. Most of those studies were conducted in high-income countries. But in a finding that could be significant for poorer countries like Uganda, the studies also show that the reduction in tobacco consumption caused by higher taxes is greatest among the lowest-income and least-educated people. (http://www.dcp2.org/pubs/DCP/46/Section/6726). Tobacco Control Journal: This publication contains a wide variety of articles on tobacco control issues and events in different countries. If you search it for Uganda, you will find numerous articles about tobacco in this country. http://tobaccocontrol.bmj.com Jackie Tumwine blog: An articulate anti-tobacco activist speaks her mind. http://blogsofbainbridge.typepad.com/jackie/2008/11/uganda-to-imple.html Plos: A study last year found that a “comprehensive” tobacco control program in California – one that sought to turn public again against smoking rather than just to help current smokers quit – quickly led to a decline in health care costs. Between 1989 and 2004, the savings added up to US$86 billion, reaching 7.3% of the state’s total health-care costs by the end of the period. http://medicine.plosjournals.org/perlserv/?request=getdocument&doi=10.1371/journal.pmed.0050178&ct=1 Tobacco control resource persons: • • •
Dr Margaret Mungherera, former President, Uganda Medical Association: 0772434652 Gilbert Muyambi, The Environmental Action Network: 0702-898629 Cathy Adengo, Public Relations Officer, British American Tobacco Uganda: 0312 200100 (Cathy_adengo@bat.com )
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