THR which is proposed as a public health strategy that aims to reduce the health risks associated with tobacco smoking has been under serious debate since the 1970s following the assertions of the late Psychiatrist Russell that smokers smoke for the nicotine, but die from the tar (Russell Michael, 1976). This study aimed to assess the knowledge and perception of Tobacco harm reduction and its communication strategies among young public health advocates in Africa.
Evidence from the quantitative aspect of our study indicated a poor knowledge of Tobacco Harm reduction among our respondents as 73.7% reported that they have not had prior experience or the right understanding of THR. This is sad as the majority of the respondents are medical students, young health professionals, health communicators, and health writers. According to La Torre G et.al (2014), Tobacco is considered a public health issue of concern and public health professionals have a huge role to play in preventing smoking and providing intervention for smoking cessation. Unfortunately, in their study conducted in Europe among healthcare professionals three-quarters of the respondents have not heard about modified-risk tobacco products (La Torre et al.,2014).
Regarding the perception of Tobacco Harm Reduction methods, most of our respondents had a positive perception of THR products; the majority (60%) of our respondents identified Nicotine Replacement Therapy as the most effective Tobacco Harm Reduction Product. To support this, 73.3% of these professionals reported that Nicotine Replacement Therapy is safer than smoking tobacco which corresponds with a report from the Royal College of Physicians (2016) indicating that there is no increased risk of heart attack, stroke, or death from using NRT when attempting to quit smoking. Similarly, in a randomized controlled trial by Murray et al. (2009), there was no link between NRT and cancer, however, an association was found between smoking and cancer(Murray et al., 2009).
Contrasting to our findings, a study in Pakistan among Public Health Professionals described some misconceptions about Nicotine where more than two-thirds of these professionals believed that nicotine causes birth defects, cancer, cardiovascular illness, and chronic obstructive pulmonary disease (Hameed & Malik, 2022).In the same vein, a study done by Nyman et.al. (2014) in the USA among Tobacco control professionals identified misconceptions about THR products among these professionals (Biener et al., 2014). These studies revealed the need to use communication interventions to better inform health professionals that nicotine in tobacco products is addictive while the chemicals, especially those associated with combustion are the major sources of risks for tobacco-related illnesses.
Similar to the findings of a past study in the UK, among smokers and Ex-smokers, by Wilson et.al, (2019), and a study in the United States using the Health Information National Trends Survey(Wilson et al., 2019), Kiviniemi& Kozlowski (2015), 48.3% of our respondents had the perception that e-cigarettes are safer than smoking tobacco(Kiviniemi& Kozlowski, 2015). Almost 3/4 of our respondents believe that THR products aid smoking cessation and more than 2/4 of our respondents reported that THR products stop smoking addiction which does not correspond to previous evidence stating that addiction to smoking is caused by nicotine-driven pleasure (Bhalerao et al., 2019).In responding to their willingness to discuss THR, 63.3% of the respondents affirmed to have ever reported or discussed THR or smoking cessation with the majority of them admitting they may in the future be putting out content on smoking cessation and prevention of tobacco use (32.5% and 30.0% respectively). Interestingly, all the respondents affirmed their enthusiasm to learn more about THR through the fellowship.
The qualitative aspect of our study explored the respondents’ opinions about the factors preventing communication and conversations about THR. Our respondents identified misinformation about THR as a barrier to THR communication which is expressed in a statement "The barriers to awareness of Tobacco Harm Reduction have been the inaccurate beliefs about THR that the residents in my community have. Many people don't know the science behind harm reduction". This is in tandem with a previous study among Nurses before their training in smoking cessation counseling. The study identified misconceptions about THR products among the nurses which could lead to inaccurate recommendations and hinder their willingness to recommend these products to smokers during their contact with them (Borrelli et al., 2007, 2008)
Our respondents identified media representation of THR as a factor preventing THR communication and conversation as expressed in this response "The media also is a barrier to THR because they only tell smokers that, "smokers are liable to die young" instead of telling smokers that they could use THR as a substitute for smoking Tobacco and live longer." However, this does not corroborate with a previous study using focus group discussions among young people where they reported that e-cigarettes were portrayed appealingly to youths and also presented as a reduced-risk cigarette (Hammal&Finegan, 2016). Similarly, Bhalerao et al. (2019) reported that tobacco companies use marketing strategies to highlight e-cigarettes as a much safer alternative and also promote flavors appealing to children (Bhalerao et al., 2019).
Our study also revealed religious and cultural barriers as a factor hindering THR communication. Some religious and cultural beliefs prohibit smoking of any form and would not allow the discussion of Tobacco and Tobacco related products among its practitioners. According to our respondents, communication about THR among people in remote areas is difficult as they lack access to most media channels used for disseminating information about THR. This is captured in a comment "Getting the message about THR to people that live in remote areas with bad access roads can be difficult unless you use the radio".
Another aspect explored by our qualitative study is the strategies the respondents feel could improve THR communication in their country of residence, and increased communication and advocacy initiative was identified as a major strategy that would help to take home THR messages to people far and wide for increased adoption.
The respondents opined that government involvement and policy development would help propagate THR messages. This is captured in such responses as "Inter-sectorial collaboration with health ministries and a wide range of awareness campaigns cutting across states and ministries of health, schools, and campuses, churches e.t.c.”, and “Policy supporting tobacco Harm Reduction should be developed and implemented to enable expert discussion on the subject matter.’’ This is not in tandem with a study done in the United States of America by Auf et.al. (2018) which opined that e-cigarette marketing poses a risk and proposes the need for stricter regulation of e-cigarette advertisement. These results add to the evidence about the risks of e-cigarette marketing and highlight the need for stricter regulation of e-cigarette advertisements (Auf et al., 2018).
Further, our respondents emphasized the need to simplify THR messages and also propagate them using the indigenous languages in the country for easy understanding and adoption by the people, especially those in rural areas. Another strategy identified by our respondents to help improve THR is increased capacity building and engagement of more THR advocates. This is captured in statements like “Advocates of THR should be properly trained and equipped. Engaging and educating Civil Society Organizations and relevant stakeholders such as healthcare professionals on the benefits of THR will help advocate for the implementation of THR strategies in Nigeria", which is also supported by (Biener et al., 2014).
Finally, because our respondents were candidates applying for a THR fellowship, it was imperative to ascertain their motivation to learn about THR. As quoted by a respondent, "As a mental health Nurse, I see this as an opportunity to contribute my quota to reduce the incidence of Substance abuse and its consequences in Africa". A public health researcher indicated that his motivation is to research the use of alternative nicotine products against the use of cigarettes to influence people to reduce/cease smoking cigarettes. A respondent who identified himself as a tobacco addict responded that his motive is to use his story to enlighten the younger generations on the harmful effects of smoking. This is captured in his response "Because I am a tobacco addict and I hate that about myself. Maybe from my stories, I can prevent younger people than me from getting hooked up on the vice".