Advancement of Tobacco Control in Ghana: Barriers & Opportunities - A brief Situation Report

Adequate tobacco control in the wake of the ongoing COVID-19 pandemic cannot be overemphasized. As a Lower Middle-Income Country (LMIC) with peculiar needs, Ghana can strengthen her tobacco control regime by advancing country-specific and resilient programmes. The Food and Drugs Authority (FDA) in partnership with WHO embarked on a national project to sensitize law enforcement officers on the existing tobacco control provisions whilst identifying control barriers peculiar to the various regional groupings. The main outcome of this meeting was the development of a tobacco control enforcement plan which defined the framework for regional participation in tobacco control. The next phase of this project is the sustainability of the regional tobacco control units and the exploration of the inclusion of traditional leadership in tobacco control policy implementation. FDA recognizes that there is an important role of Traditional Authorities, Law enforcement agencies and other state agencies as tobacco control advocates.


BACKGROUND Tobacco Use and Public Health
Tobacco use remains a significant threat to health and in turn cripples national efforts at sustainable development (Toebes & Patterson, 2019). Tobacco use is implicated in many preventable communicable and non-communicable diseases (NCDs) which contribute to the double burden of diseases in low-and middle-income countries like Ghana. Chronic respiratory disorders, cardiovascular diseases, diabetes mellitus as well as some cancers are important NCDs in this regard.
In the wake of the current COVID-19 pandemic, the critical need for effective tobacco control cannot be overemphasized (van Zyl-Smit et al., 2020). The relationship between the development of severe COVID-19 and tobacco use is well documented elsewhere. Tobacco use adds to the risk of developing severe COVID-19 disease and death. It must also be emphasized that severe COVID-19 is more prevalent in people with underlying chronic conditions such as diabetes, cancers or asthma and tobacco smoking is an important risk factor for these conditions (Simons et al, 2021) As a Lower Middle-Income Country (LMIC) with peculiar needs, Ghana can strengthen her tobacco control regime by advancing country-specific and resilient programmes.

Tobacco Control Regulations
Ghana has always retained the political will to accelerate the WHO Framework Convention for Tobacco Control (FCTC) (Singh et al., n.d.). This convention was first ratified in 2004 and since then Ghana has made significant strides in tobacco control through the passage of the Public Health Act (Act 851) 2012 and the Tobacco Control (TC) Regulations, 2016 (L.I. 2247). Part six of ACT 851 and the TC regulations have attempted to operationalize the WHO-FCTC within the context of Ghana, with considerable success and some room for improvement (Ali. 2018).

Tobacco Policy Acceleration
Considering the multifaceted and complex nature of tobacco control, the FDA with the support of the WHO has continually undertaken various projects tailored to the advancement of tobacco control policy design and enforcement. More recently, the FDA in partnership with WHO embarked on a national project to sensitize law enforcement officers on the existing tobacco control provisions whilst identifying control barriers peculiar to the various regional groupings. This approach was necessary for realizing the knowledge gap and lack of strong inclusion in tobacco policy implementation from other law enforcement agencies which significantly impeded effective tobacco control in Ghana.
The project set off with a high-level meeting which saw participation from key law enforcement groups including Ghana Health Service (GHS), National Intelligence Bureau (NIB), the local government (i.e., the municipal, district and metropolitan), military, police, customs, judiciary, tourism, and security outfit, among others.

RESULTS AND LESSONS LEARNT
The main outcome of this meeting was the development of a tobacco control enforcement plan which defined the framework for regional participation in tobacco control.
In addition, various inter-agency partnerships relevant to tobacco control were proposed. The FDA/Ministry of Tourism collaboration is one such proposal. This aims to ensure that upcoming recreational units are in conformance with the tobacco control stipulations.
In line with the outcomes of the high-level meeting and objectives of the acceleration project, the FDA embarked on a national tour to establish regional taskforces for tobacco control and disseminate the FDA strategic direction for tobacco control.
The regional training was spearheaded by the various FDA regional offices and included representatives from the Ghana Health Service, NIB, Ghana Revenue Authority, Ghana Education Service, Ghana Immigration Service, National Security, Ghana Police Service, Ghana Army, Economic and Organized Crime Office, Ghana Prisons Service, Ghana Tourism Authority, Judicial Service, Narcotics Control Commission, Traditional Authority, Ghana Standards Authority, Religious Bodies, and the Media.

Challenges to Tobacco Control
The regional interactions unearthed various tobacco control challenges cutting across the three geographical belts of Ghana. Prominent amongst the challenges were citizens' apathy in tobacco control and the lack of centers for tobacco cessation at primary healthcare units.
However, peculiar to the northern belts of Ghana was the situation of cultural practices mitigating the advancement of tobacco control. In some parts of the Northern belt of Ghana, more specifically in the Upper East amongst the Kusasis and Frafras, raw tobacco is a staple of the marriage dowry. This practice is a cultural norm, indigenous to the conservative families and signifies a show of wealth.
The law enforcement officers situated in the Northern Region described the issue of tobacco use and its associated cultural significance as a complex situation propagated by the different traditional leaders.
These cultural practices do not only downplay the global and local efforts at tobacco control but also create a false sense of tobacco safety amongst the public.

The Way Forward
The FDA as part of its comprehensive strategy in tobacco control aims to ensure that a multifaceted approach is employed. In this regard, the FDA seeks to engage traditional leaders, especially in the Northern Region as stakeholders in tobacco control discussions aimed at developing interventions for the cultural identification and use of tobacco in Ghana.
The ongoing tobacco policy acceleration project has created a more inclusive platform and a participatory model for tobacco control which involves the inputs of various stakeholders. The next phase of this project is the sustainability of the regional tobacco control units and the exploration of the inclusion of traditional leadership in tobacco control policy implementation.

CONCLUSIONS
The Ghana FDA has several decades of experience in implementing pragmatic tobacco control programs. These programs have invariably contributed to the decline in the burden of NCDs. However, the FDA recognizes that there is an important role of Traditional Authorities, Law enforcement agencies and other state agencies as tobacco control advocates. A combination of regulatory, educational, social, cultural and clinical interventions is critical to achieve adequate tobacco control and achieve the health Goals of the Sustainable Development Goals.