Support for tobacco endgame approaches: Results from a web-based survey of stakeholders from 28 African countries

The tobacco 'endgame' concept proposes moving beyond traditional tobacco control measures towards a tobacco-free future. The aim of this study is to investigate the perceptions of tobacco control stakeholders in Africa on their agreement with what endgame approaches are suited for the region to achieve a tobacco-free society.

Data were collected using a web-based cross-sectional survey hosted on Redcap. A total of 146 stakeholders from 28 African countries took the survey. Participants rated agreement with 11 proposed endgame approaches drawn from the literature and the qualitative phase of this study. Descriptive analysis was used to summarize stakeholders' level of agreement while bivariate (chi-squared and Fisher's exact tests) and adjusted modified Poisson regression analyses examined association between agreement/disagreement to endgame approaches and demographic factors. Data were analyzed using STATA v17.

All participants agreed to an integrated endgame approach while over 90% agreed with six measures (having non-addictive cigarettes, making cigarette unappealing, tobacco-free generation, regulated market model, quota/sinking lid and specific approaches for Africa). Agreements ranged from 70-85% for price caps, performance-based regulation, and non-combustible nicotine products, while only 35% supported government takeover of tobacco companies. Adjusted Poisson regression analyses showed that female stakeholders were less likely to support restricting tobacco sales by year of birth (relative risk ratio, RRR=0.89) and price caps (RRR=0.78), while PhD holders were more likely to support restricting tobacco sales by year of birth (RRR=1.29) and price caps (RRR=1.27). Stakeholders from Southern Africa were less likely to support a state takeover of tobacco companies (RRR=0.40) and performance-based regulation (RRR=0.76). Having more than 20 years of tobacco control experience lowered the support of price caps endgame measures (RRR=0.45).

Policymakers are encouraged to use insights from this study to consider multifaceted approaches aimed at addressing the problem of commercial tobacco in the African region and pave the way for a tobacco-free Africa.