Evidence and expert advocacy are shaping safer alternatives to smoking, offering hope for millions across Sub-Saharan Africa.

Evidence and expert advocacy are shaping safer alternatives to smoking, offering hope for millions across Sub-Saharan Africa.

On 1st August 2024, experts from eight Sub-Saharan countries united to launch the Declaration of Cape Town, a science-led call for tobacco harm reduction. One year later, on 1st August 2025, the movement grew – 40 delegates from 15 countries gathered as advocates in action to advance Africa’s smoke-free future. The urgency is that one person dies every four seconds from tobacco use or second-hand smoke exposure every day.

AFRICA’S ESCALATING TOBACCO CRISIS

The statistics paint a sobering picture. While global smoking rates decline, Sub-Saharan Africa faces an alarming trajectory. The number of smokers in the region is projected to rise from 66 million in 2015 to 84 million by 2025. This surge occurs as 80% of the world’s smokers now live in low-and-middle-income countries, making Africa ground zero for the tobacco epidemic’s next phase. For African healthcare professionals, these figures represent more than statistics – they forecast an overwhelming burden on already strained health systems. Smoking remains the single most preventable cause of death globally, claiming approximately 8 million lives annually. Without intervention, projections suggest over 1 billion tobacco-related deaths by century’s end.

The signatories of the Declaration are members of the non-profit organisation, Harm Reduction in Sub-Saharan Africa (HRiSSA). The group of advocates recognised that the traditional tobacco control measures alone have proven insufficient for Africa’s unique landscape. HRISSA’s strategy is rooted in pragmatism and compassion, they advocate for public health and policy differentiation for access to risk-reduced nicotine alternatives.

Providing smokers with viable options to quit combustible tobacco. This approach has been particularly effective among low income and minority communities, who have historically faced disproportionately high smoking rates. It is important that low and middle-income countries are not left behind.

THE SWEDISH PARADIGM

Sweden provides the blueprint for harm reduction success. Through widespread adoption of snus (oral moist tobacco), Sweden has achieved the world’s lowest smoking rates and tobacco-related mortality. Current smoking prevalence stands at just 5.6%, demonstrating that harm reduction can create genuine smoke-free societies.

The Swedish experience challenges conventional tobacco control wisdom. Rather than focusing solely on cessation, Swedish health authorities embraced a pragmatic approach that recognised nicotine addiction’s persistence while eliminating combustion – the primary cause of smoking-related disease. The results speak for themselves: Sweden has significantly lower rates of tobacco-related deaths and cancer incidence compared to other European nations.

NEW ZEALAND’S ACCELERATED TRANSFORMATION

New Zealand’s recent success further validates the harm reduction approach. Following implementation of regulated vaping policies through the Smoke-Free Environments and Regulated Products Amendment Act 2020, smoking rates plummeted from 16.4% in 2011 to 6.8% by 2022.

Particularly significant for African healthcare professionals is the impact on indigenous Māori populations, whose smoking rates fell from 37% to 17% during this period. This demonstrates harm reduction’s potential to address health disparities – a critical consideration for Africa’s diverse populations.

THE SCIENCE SUPPORTING HARM REDUCTION

The Declaration of Cape Town builds on robust scientific evidence. Studies, including those by Hartmann-Boyce et al., demonstrate that vaping helps smokers quit more effectively than traditional nicotine replacement therapies. Public Health England’s research indicates that reduced risk products like vaping are 95% less harmful than combustible cigarettes.

Nicotine itself, while addictive, isn’t the primary health threat. Combustion produces the tar and carbon monoxide responsible for most smoking-related morbidity and mortality. As is well known, and stated on the Cancer Research UK website, nicotine does not cause cancer.

People have used nicotine replacement therapy (NRT) safely for years in smoking cessation.

ADDRESSING VULNERABLE POPULATIONS

The Declaration emphasises harm reduction’s particular importance for vulnerable groups. Smoking exacerbates poverty and has devastating effects on individuals with HIV/AIDS – conditions prevalent across Sub-Saharan Africa.

For healthcare professionals working with these populations, harm reduction offers a pragmatic approach that acknowledges cessation difficulties while providing substantial health benefits.

The Declaration’s 35 founding members, including prominent African health advocates, stress that harm reduction isn’t about promoting nicotine use but about reducing harm for those unable or unwilling to quit entirely.

IMPLEMENTATION

The Cape Town Declaration calls for African countries to regulate reduced-risk products proportionate to their actual risks. This means creating regulatory frameworks that distinguish between high-risk combustible tobacco and lower-risk alternatives. The goal is making these alternatives affordable, accessible, and acceptable for adult smokers.

Healthcare professionals play a crucial role in this transformation. Patient education about relative risks is essential, as many believe vaping or other alternatives are as dangerous as smoking. This misunderstanding prevents potentially life-saving switches and perpetuates the tobacco epidemic.

LEARNING FROM FAILURES

Australia’s experience provides a cautionary example. Despite strict anti-vaping regulations requiring prescriptions, Australia’s smoking prevalence remains at 10.7% – significantly higher than New Zealand’s 6.8%. Punitive approaches have created black markets while failing to achieve public health goals.

The Declaration emphasises that the African region carries a disproportionate burden of disease, often under socioeconomic and healthcare constraints.

In this context, harm reduction is not simply a policy choice - it is a public health imperative.

Africa must be part of the global evidence-based conversation, but with local context and realities at the forefront.

It is critical that solutions are inclusive, pragmatic and grounded in clear scientific evidence and lived experiences.

THE HEALTHCARE IMPERATIVE

For African healthcare professionals, the Declaration of Cape Town represents both an opportunity and a responsibility.

The evidence supporting harm reduction is clear, and successful international examples provide implementation blueprints. Sweden and New Zealand demonstrate that pragmatic approaches can achieve remarkable results rapidly.