Authors : United Nations Development Programme
Site of publication : United Nations Development Programme (UNDP)
Type of publication : Report
Date of publication : June 2019
Tobacco is one of the world’s leading health threats, and a main risk factor for non-communicable diseases (NCDs) including cancers, diabetes, chronic respiratory disease and cardiovascular disease. In Sierra Leone, 28.6 percent of men and 8.2 percent of women use tobacco. Tobacco use in Sierra Leone kills approximately 3,330 citizens per year, with 68 percent of deaths occurring under age 70.
Tobacco use may displace household expenditure on basic needs, including food and education, contributing to pushing families into poverty and hunger. It imposes health and socio-economic challenges on the poor, women, youth and other vulnerable populations. Meanwhile, tobacco production causes environmental damage including soil degradation, water pollution and deforestation. Given the far-reaching development impacts of tobacco, effective tobacco control requires the engagement of non-health sectors within the context of a whole-of-government approach.
In Sierra Leone, 28.6 percent of men and 8.2 percent of women use tobacco [1]. Tobacco use in Sierra Leone kills approximately 3,330 citizens per year, with 68 percent of deaths occurring under age 70
- Tobacco control in Sierra Leone: Status and context
The 2013 Demographic and Health Survey (DHS) finds that approximately 18 percent of adults age 15 to 49 in Sierra Leone use at least one form of tobacco. The vast majority of tobacco is consumed by smoking cigarettes. Previously, the 2009 STEPS survey showed that most smokers (87 percent) smoke every day, and that smokers on average consume 7.2 cigarettes per day [20]. Less than three percent of adults use smokeless tobacco. Rates of tobacco use differ among demographic profiles. Rural areas have a higher prevalence of tobacco use (35.1 percent of men and 9.7 percent of women) compared to urban areas (14.2 percent of men and 5.5 percent of women), as reflected in Figure 1 which shows lower rates of use in the urbanized Western region that contains the capital, Freetown. Tobacco use prevalence is higher among men than women (28.6 percent of men use tobacco, compared to 8.2 percent of women).
3.2 Tobacco control regulatory measures
In 2018, Sierra Leone demonstrated its commitment to tobacco control by increasing taxes on tobacco products. However, to further protect the health of its population, Sierra Leone must commit to honoring its obligations as a Party to the Framework Convention on Tobacco Control by implementing a package of policy measures proven to reduce demand for tobacco.
Taxes
In 2018, Sierra Leone successfully enacted a 30 percent excise tax on tobacco products. The level of taxation remains short of the WHO recommendation that taxes represent at least 75 percent of the retail price of tobacco products, inclusive of at least a 70 percent excise tax. Additional tax increases—and ensuring uniform taxation across all tobacco products—can further draw the prevalence curve downward, achieving health and revenue gains for the government.
The 2013 Demographic and Health Survey (DHS) finds that approximately 18 percent of adults age 15 to 49 in Sierra Leone use at least one form of tobacco. The vast majority of tobacco is consumed by smoking cigarettes
Ban Smoking in Public Places
Sierra Leone does not currently ban smoking in public places, such as healthcare facilities, educational facilities, government buildings, offices, public transportation, restaurants, and cafes . Enacting a complete ban on smoking in public places will help to change norms around smoking, and protect citizens from being exposed to secondhand smoke
Graphic Warning Labels
Currently, Sierra Leone does not require tobacco product packaging to carry graphic warning labels, nor does it mandate plain packaging—neutral-color packaging, without branding and logos . Graphic warning labels confront tobacco users with the consequences of tobacco use. Plain packaging works synergistically with warning labels to reduce the appeal of tobacco products by removing opportunities for tobacco companies to brand and promote their products.
Anti-tobacco Mass Media Campaigns
Sierra Leone has undertaken information campaigns to raise awareness about tobacco control issues, and to educate the public about the harms of tobacco use and the benefits of tobacco cessation [17]. However, the campaigns were not aired on mass media platforms (e.g. television, radio, internet). Targeted, national-scale mass media campaigns that are researched and tested for impact, and that reach a wide audience through major forms of media, are important for tobacco control.
Tobacco advertising, promotion, and sponsorship (TAPS)
Tobacco advertising, promotion, and sponsorship (TAPS) are not regulated in Sierra Leone. By banning direct advertisements on TV, radio, newspapers, the internet, and other media outlets, and also banning indirect advertising through mediums such as point-of-sale advertising, or product placement in television or films, Sierra Leone can reduce the channels through which tobacco companies promote products to consumers. Bans on promotional activities—such as free distribution of tobacco products or promotional discounts—and sponsorship offer additional opportunities to restrict marketing.
3.3 National coordination, strategy and planning
Sierra Leone does not currently have a comprehensive tobacco control law, but the Government has prioritized drafting and passing tobacco control legislation. Tobacco control legislation is the most impactful step the Government can take to reduce the burden of tobacco. The tobacco control measures can be mandated through passage of a single comprehensive tobacco control law. Such a law, if passed and implemented, would not only reduce the health burden caused by tobacco—thereby resulting in savings to the Government and citizens of Sierra Leone—but it would result in substantial tax revenue increases which the Government can use to finance development. By raising taxes on tobacco products, a new tobacco control law would assist Sierra Leone in becoming less dependent on donor contributions.
Sierra Leone will need to build capacity and strengthen multisectoral coordination to effectively implement tobacco control measures. The tobacco control law could mandate a multisectoral task force to oversee and coordinate implementation of tobacco control measures. Such a task force was created ad-hoc several years ago but has not been active. Further, to support the passage and implementation of a new tobacco control law, the Government—led by the Ministry of Health and Sanitation—can draft and adopt a multisectoral national strategy for tobacco control. There was a national tobacco control strategy through 2016 but it has not been renewed. Stronger coordination through a multisectoral, national task force and strategy can help Sierra Leone overcome challenges in capacity to implement, including effective tax administration and reducing illicit trade.
Sierra Leone faces the challenge of illicit trade stemming from neighboring Guinea and Liberia. Coordination between law enforcement and border authorities including customs, can help stem this issue. Sierra Leone does not have a tax stamp regime and has not signed and ratified the Protocol to Eliminate Illicit Trade in Tobacco Products. This protocol includes measures that would help the Government combat illicit trade.
- Results
5.1. The current burden of tobacco use: health and economic costs
Tobacco use undermines economic growth. In 2017, tobacco use caused 3,330 deaths in Sierra Leone, 68 percent of which occurred among citizens under the age 70. As a result, Sierra Leone lost productive years in which those individuals would have contributed to the workforce. The economic losses in 2017 due to tobacco-related premature mortality are estimated at SSL 201.1 billion. While the costs of premature mortality are high, the consequences of tobacco use begin long before death.
As individuals begin to suffer from tobacco-attributable diseases (e.g. heart disease, strokes, cancers), expensive medical care is required to treat them. Spending on medical treatment for illnesses caused by smoking cost the Government SSL 32.9 billion in 2017 and caused Sierra Leone citizens to spend SLL 45 billion in out-of-pocket (OOP) healthcare expenditures. OOP healthcare expenditures have significant implications for poverty reduction efforts given the relationship between OOP health spending and impoverishment. Private and other healthcare entities spent about SSL 30.5 billion for treating tobacco-attributable diseases. In total, smoking generated SSL 108.4 billion in healthcare expenditures. In addition to generating healthcare costs, as individuals become sick, they are more likely to miss days of work (absenteeism) or to be less productive at work (presenteeism). In 2017, the costs of excess absenteeism due to tobacco-related illness were SSL 15.4 billion and the costs of presenteeism due to cigarette smoking were SSL 46.2 billion.
Finally, even in their healthy years, working smokers are less productive than non-smokers. Smokers take at least ten minutes per day more in breaks than non-smoking employees. If ten minutes of time is valued at the average workers’ salary, the compounding impact of 415,000 employed daily smokers taking ten minutes per day for smoke breaks is equivalent to losing SSL 32.7 billion in productive output annually. In total, tobacco use cost Sierra Leone’s economy SSL 403.9 billion3 in 2017, equivalent to about 1.5 percent of Sierra Leone’s GDP that year.
- Conclusion and recommendations
Each year, tobacco use costs Sierra Leone SLL 403.9 trillion in economic losses and causes substantial human development losses. Fortunately, the investment case shows that there is an opportunity to reduce the social and economic burden of tobacco in Sierra Leone. Enacting the recommended multisectoral tobacco control provisions would save over 1,300 lives each year and reduce the incidence of disease, leading to savings from averted medical costs and averted productivity losses. In economic terms, these benefits are substantial, adding to SLL 1.9 trillion over the next fifteen years. Further, the economic benefits of strengthening tobacco control in Sierra Leone greatly outweigh costs of implementation (SLL 1.9 trillion in benefits versus just SLL 0.07 trillion in costs).
Each year, tobacco use costs Sierra Leone SLL 403.9 trillion in economic losses and causes substantial human development losses
By investing now in six proven tobacco control measures, Sierra Leone would not only reduce tobacco consumption, improve health, reduce government health expenditures and grow the economy, it would also reduce hardships among Sierra Leoneans, particularly among those with low incomes. As the investment case shows, contrary to common misperception, tobacco control would benefit people in lower-income categories the most. For example, higher cigarette taxes would not only help those with lower incomes (and others) avoid out-of-pocket health expenditures, it would also raise revenue for the Government of Sierra Leone that can advance its sustainable development efforts, a priority identified by the Ministry of Trade and Industry. Many countries reinvest savings from healthcare expenditures and revenue from increased tobacco taxes into national development priorities such as universal health coverage, which is another proven pro-poor and inclusive policy measure. The investment case has identified strong tobacco control investments that Sierra Leone can make. It offers compelling economic and social arguments to implement core WHO FCTC measures.