Africa is already beleaguered by infectious diseases, such as AIDS and malaria, but now the continent's residents face growing health threats from preventable illnesses brought on by lifestyle changes, such as from poor diets and smoking.

In an effort to stave off these maladies, advocates have turned their sights on tobacco use, which is on the rise throughout Africa and projected to double by 2021. Of the approximately one billion people across the world who use tobacco, 60 million to 80 million live in Africa.

Along with lobbying for higher tobacco taxes and broader public health messages, advocates are hoping to eliminate smoking in public places in an effort to protect people from both first- and second-hand smoke.

About a billion people worldwide live in municipalities where smoking is outlawed in public places, according to a report published Tuesday by Global Smokefree Partnership (a joint initiative backed by the American Cancer Society, Johns Hopkins Bloomberg School of Public Health, Johnson & Johnson, Pfizer and 14 other entities) and announced in time for the African Organization for Research and Training in Cancer's (AORTIC) "Cancer in Africa" conference taking place this week in Dar es Salaam, Tanzania. Reducing secondhand smoke exposure can reduce the rates of lung cancer, heart attacks and breathing trouble in populations.

"It's one of the most frustrating things," Thomas Glynn, director of International Cancer Control for the American Cancer Society (ACS) and acting head of the Global Smokefree Partnership says, about knowing that many nicotine-related illnesses can be prevented—especially among those who do not smoke—with the right laws and education.

A few countries in Africa have taken a firm stance on public smoking. the Indian Ocean nation, Mauritius, and South Africa have passed strong national smoke-free laws, and Nigeria's capital, Abuja, has a local ordinance in effect. But in many areas throughout the continent, politically connected and economically strong tobacco companies—and their addictive products—are shaping up to be a substantial opponent (British American Tobacco, a member of the industry group the Tobacco Institute of Southern Africa, did not repond to request for comment).

A hit on health
Tobacco causes about 5.4 million deaths worldwide each year, according to the World Health Organization (WHO), a number that is set to rise in the coming decades even as use decreases in many developed countries. But it is not just the smokers who suffer from the ill effects of their habits.

Since 1986 secondhand smoke has been recognized internationally as a contributor to lung cancer and, in 2006, the U.S. Surgeon General went so far as to say "there is no safe level of exposure to secondhand smoke." These findings, however, have not widely been put into regulatory action, leaving some 90 percent of Africans without local or national smoke-free laws, the new report notes. For example, in Tunisia, where tobacco use is especially high, even teachers and doctors smoke at work, according to a report issued earlier this year by the Economist Intelligence Unit, a London-based firm that provides business and market research, and backed by Pfizer.

Aside from the millions of tobacco-related deaths annually, the range of long-term disability that tobacco smoke exposure can induce also takes a toll on health and productivity. "We focus on lung cancer deaths, but more people are disabled by emphysema and heart disease and can't provide for their families," Glynn says.

In developed countries, heart attacks in areas with smoke-free laws dropped by 36 percent three years after laws went into effect, according to a report released in September by the American Heart Association. California, one of the first states in the U.S. to institute substantial local laws banning public smoking, has seen a reduction in lung cancer, Glynn notes. "From a biological plausibility standpoint, there's no reason we wouldn't see a similar decrease" in African countries, he says.

"The science is established," Glynn says. "It's now the legal and regulatory issues that are being dealt with." But in cities such as Abuja, where more than half of school students do not know that secondhand smoke can be hazardous, creating public support for laws and enforcement can be challenging. And in countries that grow tobacco, such as Tanzania, where about 6 percent of the country's income is tied to the crop, limiting the product's range can be met with formidable financial resistance.

Economic drag
Tobacco industry supporters have cited potential hits to businesses and the economy that public smoking limits could spark. The ACS report, however, points to data showing that in fact the hospitality industry—including bars and restaurants—have not suffered under smoking bans. And, notes Gary King, a professor of behavioral health and sociology at The Pennsylvania State University in University Park, many tourists from Europe and the U.S. have come to expect smoke-free environments at their destinations.

"There are some costs associated with declines in consumption," including loss of livelihood for tobacco farmers and increased smuggling, notes Evan Blecher, a tobacco control economist with the ACS in South Africa, "although these costs are outweighed by the benefits."

Direct spending on nicotine consumption racks up some $590 million each year in Nigeria, and indirect costs such as the loss of productivity have been tallied in Kenya at about $1.2 billion.

Limiting places people can smoke is not the only way to get people to kick the habit. Blecher says that raising cigarette taxes—which boosts government income—is probably the best way to curb use.

International pull
The Framework Convention on Tobacco Control (FCTC), as part of a larger WHO treaty, went into effect in February 2005 and requires that signatory nations commit to protecting citizens from public secondhand smoke by 2012. In the 168 countries that have ratified the treaty, "it's being implemented in a checkerboard fashion," Glynn says. (Unlike many African nations, the U.S., which has passed smoke-free laws on the state and local level, has not signed the agreement.)

Even as other countries have had success instituting smoke-free laws, no one process will prove to be perfect worldwide. Passing—and enforcing—laws that curtail public tobacco use depend on each nation's specific history, legal system and popular attitudes, Glynn notes. Legal gray areas have kept lawyers and policy experts debating the finer points of many proposals, he adds.

When it comes to tobacco consumption, Africa's varied regions have disparate histories, cultures and attitudes. Although the Global Smokefree Partnership's report focuses on sub-Saharan Africa, "the problem is just as severe—if not more so—in north Africa, where tobacco use and consumption has a longer history and more established independent culture," King says. In some parts of the continent, such as the west where tobacco products have been around since the slave trade era, nicotine is often delivered via harder to measure mediums such as pipes and chewing tobacco.

Trimming tobacco use may also prove to be a paradoxical culture clash. "Smoking represents a cultural connection to the West," King says. And as more people in Africa obtain disposable incomes, more will add luxury products—such as cigarettes—to their lifestyles, he notes. Meanwhile, onlookers in the West push for rapid reversal of these potentially harmful trends, King explains, noting that many advocacy groups are pushing for changes at "ludicrous" rates. In the U.S., for example, even the existing patchwork of smoke-free laws has taken decades to enact—"nothing happened overnight," he says.

Open markets
Why has Africa become the new international target for stemming the tobacco tide? "You have to look at it from the perspective of the tobacco industry," Glynn says.

Africa is home to about 12 percent of the world's population but only 4 percent of the world's tobacco users. "That makes it a battleground, but that also makes it a golden opportunity for prevention," he says.

"No one has ever accused the tobacco industry of being stupid," Glynn says, noting that they have an obligation to look out for their shareholders just like any enterprise. But, he notes, their tactics can be strident. Aside from lobbying politicians to weaken smoke-free legislation, such as by keeping some smoking areas in public places or mandating ventilation rather than complete bans, the companies have targeted their advertising to women and even children. "I have seen children wearing child-sized Marlboro T-shirts," Glynn says.

Smoking is not as prevalent among women in Africa, which is not uncommon in developing regions, says Fred Pampel, associate vice chancellor for research at the University of Colorado at Boulder, who has studied the demographics of tobacco use in Africa. But that is not necessarily for the better. "Often adoption of smoking by females lags behind males by about 10 years," he says, so "things could change quickly for the worse."

The sheer number of young people also presents both promise and potential trouble for nicotine-related health issues in Africa. As King notes: "What the tobacco industry is banking on is the reservoir of nonsmokers among the youth population."

Smoking out statistics
As propagating health messages to many African citizens—and health care workers—about tobacco's hazards has proved difficult, so has gathering data about its use. Even figures about tobacco consumption used in the ACS's report are far from definitive. "They're educated estimates," Glynn says. Knowing the data about who smokes—and why—would help health officials better spread awareness.

Better numbers require better surveillance and more cancer registries. Funding data-gathering work, however, can present a challenge when many advocates point to cancer patients who need immediate treatment.

Nicotine-related diseases are only some of the noncommunicable sicknesses killing people in Africa, but Glynn proposes that with the spread of the vaccine for cervical cancer and improved breast and prostate cancer screening, those forms of malignancy will decrease, whereas tobacco-related lung cancer will rise.

"It's very sad in that this is very predictable," Glynn says about "the march of the Western lifestyle" that brings along with it tobacco use, unhealthy diets, less physical activity—and more preventable diseases. But he does not believe extinguishing these threats are insurmountable challenges, agreeing with other experts that it will take a combination of education, political will, grassroots efforts and global awareness.

"Infectious diseases have been at the top of the world health care agenda," Glynn says, but for the first time, noncommunicable afflictions are killing more people worldwide than infectious ones. And if more people in Africa continue to pick up the habit, ACS's Blecher says, "it will not be long until tobacco is up there with HIV/AIDS and malaria."