Smoking prevalence in Sub-Saharan Africa shows the urgent need for effective regulation
A new academic study on smoking rates in Sub-Saharan Africa has given cause for concern and shows the need for an urgent review of existing approaches to tobacco control in the region.
Worldwide, more than 1.1 billion people smoked tobacco in 2019, resulting in about 8 million deaths. 1 in 5 adults worldwide are consuming tobacco. Globally, over 22 000 people die from tobacco use or second-hand smoke exposure every day — that equates to one person every 4 seconds. (Ref: The Tobacco Body, 31 May 2019 Publication. https://www.who.int/publications/i/item/WHO-NMH-PND-19.1)
While smoking rates have declined globally, progress in less developed regions, including Sub-Saharan Africa, has been slower.
Adolescent smoking remains a concern, with a 23.5% lifetime prevalence in Sub-Saharan Africa recorded in 2018 and no updated data to date.
To address the deficiency in data, Belete H, et al1 searched databases for peer-reviewed observational online studies published from January 2018 to 2023 and calculated the weighted pooled smoking prevalence using meta-regression analysis.
A total of 10 310 unique records were screened and 340 studies were included for full-text screening, of which 195 studies were retained for the meta-analysis, amounting to 1,3 million participants.
The findings showed overall lifetime smoking prevalence in Sub-Saharan Africa at 8.8% (95% confidence interval [CI] 5.1, 13.4%), with 10.8% (CI 4.0%, 19.9%) having smoked in the past year and 5.8% in the past 6 months.
Regional disparities in adult smoking rates revealed notable trends: the southern SSA region showed a lifetime prevalence of 37.1%, while South Africa reported a 12-month prevalence of 59.2% and a 6-month prevalence of 19.6%. Namibia's lifetime prevalence stood at 28.9%. This is comparable to the lifetime prevalence in the United States, which is 19% and regularly tracked and monitored through population data. However, the SSA region confronts substantial obstacles, including insufficient healthcare resources, inadequate implementation of tobacco control policies, and the burden of hosting two-thirds of the world's most impoverished populations.
As the authors noted: 'these results underscore the growing rates of tobacco use in Sub-Saharan Africa, reinforcing the idea that high smoking prevalence is increasingly concentrated in low-income regions like Sub-Saharan Africa. Without collective action, smoking rates in SSA could rise, triggering serious health and economic issues. The smoking epidemic is shifting toward low-income countries. Without urgent policy action, SSA risks falling short of the WHO's 2025 goal to cut tobacco use by 30%.' 2
They recommend, among others, that countries in the region strengthen their tobacco monitoring systems and adopt innovative strategies for smoking prevention. This lack of comprehensive data collection not only hinders the precise assessment of smoking prevalence but also masks the full scope of smoking-related public health challenges within the SSA region. It is critical to have consistent enforcement of international tobacco control measures to effectively reduce smoking rates in all population groups.
Another part of the solution is suggested by research from Australia and New Zealand which compares vaping and smoking trends in the two countries in the context of their different regulatory policies.3
The study shows that between 2016 and 2023, the smoking rate in New Zealand (from 14.5% to 6.8%) fell twice as fast than in Australia (from 12.2% to 8.3%). With a significant decline in the disadvantaged and indigenious populations. Smoking prevalence fell three times faster in New Zealand's lowest socioeconomic group than in the same population in Australia (12% per year vs 4% per year). New Zealand's liberal vaping laws were linked to faster smoking decline compared to Australia.
The authors note that the largest smoking reductions in both countries were in young adults, who also reported the highest vaping rates, while youth smoking rates declined in both countries to very low levels.
Turning to the contrasting regulatory approaches between the two countries, they argue that Australia has taken a 'highly restrictive precautionary approach to regulating nicotine vaping products by classifying nicotine e-liquid as a prescription-only 'unapproved' medicine since 2011'. Vapers could only buy nicotine e-liquid legally with a doctor's prescription, but this prescription model has resulted in low rates of prescribing, low compliance by vapers and the emergence of a large illicit market controlled by criminal networks, which supplies over 90% of vaping products.
'In contrast, New Zealand has adopted a more risk-proportionate approach. It has endorsed vaping as a tool for smoking cessation and encouraged its use among adults unable to quit smoking through other means.'4
According to Action on Smoking and Health (ASH) New Zealand, there is minimal evidence of a significant illicit market for vaping products in that country. Australia's stringent medical model for vaping has unintentionally nurtured a flourishing and increasingly violent black market. At present, over 90% of vaping products available in Australia are sourced from unlawful channels, devoid of safety regulations and readily accessible to young individuals. Recent reports have revealed that more than 220 vape and tobacco shops across the nation have been targeted in firebombing attacks.
The findings of the study suggest that vaping has not served as a gateway to smoking. Instead, it appears to have steered young individuals away from the use of combustible tobacco products.
The Australian medical model for vaping serves as a cautionary tale about the complexities of regulation for policymakers in Sub-Saharan Africa. Without addressing the black market's proliferation and its accompanying social harms, the intended benefits of strict vaping policies may be overshadowed by their unintended consequences. A more nuanced, evidence-based strategy could be pivotal in achieving the twin goals of public health and safety and may contribute to more rapid progress in reducing smoking prevalence in the region.
Insert new reference: Ref: The Tobacco Body, 31 May 2019 Publication. https://www.who.int/publications/i/item/WHO-NMH-PND-19.1)
1. Belete H, et al. Tobacco smoking in Sub-Saharan Africa: A systematic review and meta-analysis. Drug Alcohol Rev. Feb 2025; 1-13.
2. Belete H, et al. Tobacco smoking in Sub-Saharan Africa: A systematic review and meta-analysis. Drug Alcohol Rev. Feb 2025; 1-13.
3. Mendelsohn CP et al. Do the differing vaping and smoking trends in Australia and New Zealand reflect different regulatory policies. Addiction, 2025
https://pubmed.ncbi.nlm.nih.gov/39924453/
4. Mendelsohn CP et al. Do the differing vaping and smoking trends in Australia and New Zealand reflect different regulatory policies. Addiction, 2025
https://pubmed.ncbi.nlm.nih.gov/39924453/
About HRiSSA:
The Harm Reduction Advocacy in Sub-Saharan Africa society (HRiSSA) is a non-profit organisation dedicated to delivering appropriate, quality patient care supported with the latest scientific evidence based data. The society is administered by harm reduction experts and as such has a latitudinous collaboration across both African and global harm reduction focus groups and research networks. Patient advocacy and Public Health are an integral focus of the Society and to this end, information and resources are made available to patients and their families on all aspects of harm reduction in Sub-Saharan Africa. For more information, please contact : office@hrissa.org.za (www.HRISSA.org.za)
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