**5.3 Tobacco and alcohol use in African cities**

The WHO considers tobacco use as the single leading cause of avoidable death and ill health, contributing to lung cancer, chronic respiratory disease and cardiovascular disease [63]. While the use of cigarette and other tobacco products has declined in high-income countries [64], cigarette use in LMICs including in SSA is rising [65]. Demographic Health Surveys (DHS) conducted in 16 African countries revealed that cigarette use was highest among urban dwellers, less educated, and lower socioeconomic status individuals [66]. Consistent with previous studies in Africa, urban residents are most at risk for cigarette use [67], and start smoking at a younger age [68]. A study by Williams et al., (2008) in Cape Town concluded

*Public Health in Developing Countries - Challenges and Opportunities*

their controls in the rural areas. In addition, migrants' mean urinary sodium: potassium ratio, weight and pulse rate were higher than for controls [43]. Cooper et al., also hypothesized that environmental and behavioral changes that occur when individuals move from rural to urban settings all coalesce to increase predisposition

*Prevalence of hypertension by rural–urban residence in selected African countries. Source of data: World* 

Urban poverty which is common in African cities, is also known to mediate deleterious risks factors for hypertension among urban residents [45]. In LMICs, poverty exposes people to behavioral risk factors for NCDs and in turn, resulting NCDs become an important driver for poverty. The urban poor experience increased vulnerability to unhealthy diets and physical inactivity. Evans et al., (2010) found that informal settlements within cities in South Africa had unhealthy diets and inadequate physical activity because they lacked access to organized markets for healthy foods, and had inadequate resources for physical activity [46]. Urban living in South Africa, Tanzania and Cameroon was also reported to be associated with increased exposure to tobacco use, excessive alcohol intake, unhealthy diets (high in salt, and sugar and less in fiber) and also physical inactivity [47, 48]. In the next section, we review how urban environment modifies NCD risk

**5. How urban environment determines the rise of NCD risk factors** 

There is evidence alluding to the link between diet and development of overweight, obesity and occurrence of NCDs [49]. However, the understanding of the nexus between urbanization and changes in dietary patterns and nutrient intakes in Africa remains limited. As African cities grow, the rise in urban population's increases pressure on arable land for farming, and coupled with rural urban migration, this reduces the ratio of food producers to food consumers [16]. This

**36**

factors.

**in African cities**

**5.1 Unhealthy diets in African cities**

to hypertension [44].

**Figure 4.**

*Health Survey (2003).*

that urbanicity was associated with smoking attitudes among women [69]. Notably, increased marketing of tobacco products target women and youths in urban SSA [66]. Young adults in African cities, for example in Nairobi, Kigali and Dar-essalaam, have taken into trendier smoking habits such as *"shisha" (pipe smoking)* [70–72]. In addition, since informal settlements in the cities are overcrowded, there is increased the risk of second hand smoking and indoor pollution from cooking– all linked to cardiovascular and respiratory complications [73].

Comparative literature about alcohol use in urban and rural settings is rare. Some studies have linked urban living to the rise of psychological distress and alcohol-related problems. However, there is paucity of research that investigates the link between urbanization stress and alcoholism in SSA [74]. Similarly, harmful use of alcohol is often associated with injuries, violence, crime, suicide and risky sexual behaviors [75].

## **5.4 Obesity and overweight**

The link between obesity, poor health outcomes and all-cause mortality is well established. Obesity is known to increase the likelihood of diabetes, hypertension, coronary heart disease, and stroke, certain cancers, obstructive sleep apnoea and osteoarthritis. It also negatively affects reproductive performance [24, 27, 76]. Research evidence now characterizes the rapid rise in obesity levels in urban parts of Africa over the last 25 years as an epidemic. A study in Nairobi informal settlements found three times higher obesity prevalence than that rural areas in Kenya [77]. An analysis of demographic and health survey data from 24 African countries over the past 25 years revealed a consistent increase in obesity levels in all study countries. Obesity more than doubled or tripled in 12 of the 24 countries including Kenya, Benin, Niger, Rwanda, Ivory Coast and Uganda, Zambia, Burkina Faso, Mali, and Malawi, while Tanzania experienced a three-fold increase over the same period [78]. Substantial differences were observed between countries: Egypt and Ghana had the highest prevalence of obesity in the survey estimated at 39 and 22%respectively [79]. Obesity was higher among women aged between 15 and 49 years and those living in urban areas [80]-see **Figure 5**.

**Figure 5.**

*Differences in urban and rural overweight and obesity prevalence in Africa. Source of data: Demographic Health Surveys (DHS).*

**39**

*Non-Communicable Diseases and Urbanization in African Cities: A Narrative Review*

Several studies have described the role of urbanization in the rising obesity epidemic in the African continent [79–81]. Urbanization along with socioeconomic transformation lead to increased access to high energy-dense foods and more sedentary lifestyles resulting in a positive energy balance leading to obesity. Access to cheap foods, high in fat and sugar content among the urban poor is easier than in rural communities, thus the higher prevalence of obesity in urban areas [82]. In an analysis of data from seven African countries including Malawi, Senegal, Kenya, Ghana, Tanzania, Niger and Burkina Faso, Ziraba et al., found that the greatest increase in prevalence of overweight and obesity over a ten-year was among the

Many interventions for prevention and control of NCDs exist but because most African countries have limited resources, choices have to be made about which of the interventions are prioritized [84]. WHO proposed several NCD "best-buy" strategies - proven and cost-effective approaches for addressing NCDs- within LMICs through tacking of the modifiable risk factors for NCDs [85]. Examples of the "best buys" include increasing taxes on tobacco and alcohol, legislation to restrict smoking zones, bans on advertising, reducing salt and sugar in food and raising public awareness on dangers of all risk factors for NCD and promoting healthy behaviors. A number of African governments made commitments in domesticating and implementing NCD related international commitments, such as the Global NCD Action Plan 2013–2020 with targets and indicators to accelerate NCD control [86]. Nevertheless, progress has been slow, and in some cases off-track in achieving the NCDs indicators by the set deadlines [87]. Scarcity of resources and several competing priorities in the health sectors across African countries limits the ability of countries to achieve their targets. A recent WHO NCD Progress Monitor report revealed that less than half of WHO Member States have set NCD targets/indicators to track progress of implementing NCD "best buys" [88]. Some of the "best-buys" that have been implemented by African countries include; taxes and legislations to create a protective environment that limits exposure to harmful

Both excise and sales tax on tobacco products in Kenya and South Africa were

increased [89]. Similarly, several countries including Botswana, Kenya, The Gambia, Ghana, South Africa, Tanzania, and Zimbabwe have imposed taxes on alcoholic beverages [90]. While the enforcement of the alcohol and tobacco policies may be lacking the needed regulatory teeth, there is some evidence suggesting higher levels of alcohol and tobacco abstinence in countries implementing these interventions compared to countries without any regulations [90]. Between 1993 and 2009, cigarettes sales declined by 30% in South Africa, and the rate of smoking among adults dropped by 25%, even as government revenues from tobacco taxes increased by 800% [91, 92]. South Africa imposed taxes on sugary drinks in 2017, becoming the first African country to do so, in an attempt to reduce excessive consumption of sugary drinks [93], the effect of this is yet to be seen. South Africa also passed a legislation to enforce salt reductions in the food industry by establishing maximum sodium content limits to be achieved by 2019 [94]. Some countries are now pushing for bans on alcohol advertising. In Gambia, alcohol advertising is

Some African cities have chosen a more positive and interactive approach through health promotion such as raising awareness about NCDs and encouraging disease screening through campaigns (e.g. for hypertension and diabetes). Most of

*DOI: http://dx.doi.org/10.5772/intechopen.89507*

poorest people living in the cities [83].

**6. Control of NCDs in Africa cities**

behaviors especially for the most vulnerable.

banned on national television and radio.

*Non-Communicable Diseases and Urbanization in African Cities: A Narrative Review DOI: http://dx.doi.org/10.5772/intechopen.89507*

Several studies have described the role of urbanization in the rising obesity epidemic in the African continent [79–81]. Urbanization along with socioeconomic transformation lead to increased access to high energy-dense foods and more sedentary lifestyles resulting in a positive energy balance leading to obesity. Access to cheap foods, high in fat and sugar content among the urban poor is easier than in rural communities, thus the higher prevalence of obesity in urban areas [82]. In an analysis of data from seven African countries including Malawi, Senegal, Kenya, Ghana, Tanzania, Niger and Burkina Faso, Ziraba et al., found that the greatest increase in prevalence of overweight and obesity over a ten-year was among the poorest people living in the cities [83].

### **6. Control of NCDs in Africa cities**

*Public Health in Developing Countries - Challenges and Opportunities*

all linked to cardiovascular and respiratory complications [73].

and 49 years and those living in urban areas [80]-see **Figure 5**.

that urbanicity was associated with smoking attitudes among women [69]. Notably, increased marketing of tobacco products target women and youths in urban SSA [66]. Young adults in African cities, for example in Nairobi, Kigali and Dar-essalaam, have taken into trendier smoking habits such as *"shisha" (pipe smoking)* [70–72]. In addition, since informal settlements in the cities are overcrowded, there is increased the risk of second hand smoking and indoor pollution from cooking–

Comparative literature about alcohol use in urban and rural settings is rare. Some studies have linked urban living to the rise of psychological distress and alcohol-related problems. However, there is paucity of research that investigates the link between urbanization stress and alcoholism in SSA [74]. Similarly, harmful use of alcohol is often associated with injuries, violence, crime, suicide and risky sexual

The link between obesity, poor health outcomes and all-cause mortality is well established. Obesity is known to increase the likelihood of diabetes, hypertension, coronary heart disease, and stroke, certain cancers, obstructive sleep apnoea and osteoarthritis. It also negatively affects reproductive performance [24, 27, 76]. Research evidence now characterizes the rapid rise in obesity levels in urban parts of Africa over the last 25 years as an epidemic. A study in Nairobi informal settlements found three times higher obesity prevalence than that rural areas in Kenya [77]. An analysis of demographic and health survey data from 24 African countries over the past 25 years revealed a consistent increase in obesity levels in all study countries. Obesity more than doubled or tripled in 12 of the 24 countries including Kenya, Benin, Niger, Rwanda, Ivory Coast and Uganda, Zambia, Burkina Faso, Mali, and Malawi, while Tanzania experienced a three-fold increase over the same period [78]. Substantial differences were observed between countries: Egypt and Ghana had the highest prevalence of obesity in the survey estimated at 39 and 22%respectively [79]. Obesity was higher among women aged between 15

**38**

**Figure 5.**

*Health Surveys (DHS).*

behaviors [75].

**5.4 Obesity and overweight**

*Differences in urban and rural overweight and obesity prevalence in Africa. Source of data: Demographic* 

Many interventions for prevention and control of NCDs exist but because most African countries have limited resources, choices have to be made about which of the interventions are prioritized [84]. WHO proposed several NCD "best-buy" strategies - proven and cost-effective approaches for addressing NCDs- within LMICs through tacking of the modifiable risk factors for NCDs [85]. Examples of the "best buys" include increasing taxes on tobacco and alcohol, legislation to restrict smoking zones, bans on advertising, reducing salt and sugar in food and raising public awareness on dangers of all risk factors for NCD and promoting healthy behaviors. A number of African governments made commitments in domesticating and implementing NCD related international commitments, such as the Global NCD Action Plan 2013–2020 with targets and indicators to accelerate NCD control [86]. Nevertheless, progress has been slow, and in some cases off-track in achieving the NCDs indicators by the set deadlines [87]. Scarcity of resources and several competing priorities in the health sectors across African countries limits the ability of countries to achieve their targets. A recent WHO NCD Progress Monitor report revealed that less than half of WHO Member States have set NCD targets/indicators to track progress of implementing NCD "best buys" [88]. Some of the "best-buys" that have been implemented by African countries include; taxes and legislations to create a protective environment that limits exposure to harmful behaviors especially for the most vulnerable.

Both excise and sales tax on tobacco products in Kenya and South Africa were increased [89]. Similarly, several countries including Botswana, Kenya, The Gambia, Ghana, South Africa, Tanzania, and Zimbabwe have imposed taxes on alcoholic beverages [90]. While the enforcement of the alcohol and tobacco policies may be lacking the needed regulatory teeth, there is some evidence suggesting higher levels of alcohol and tobacco abstinence in countries implementing these interventions compared to countries without any regulations [90]. Between 1993 and 2009, cigarettes sales declined by 30% in South Africa, and the rate of smoking among adults dropped by 25%, even as government revenues from tobacco taxes increased by 800% [91, 92]. South Africa imposed taxes on sugary drinks in 2017, becoming the first African country to do so, in an attempt to reduce excessive consumption of sugary drinks [93], the effect of this is yet to be seen. South Africa also passed a legislation to enforce salt reductions in the food industry by establishing maximum sodium content limits to be achieved by 2019 [94]. Some countries are now pushing for bans on alcohol advertising. In Gambia, alcohol advertising is banned on national television and radio.

Some African cities have chosen a more positive and interactive approach through health promotion such as raising awareness about NCDs and encouraging disease screening through campaigns (e.g. for hypertension and diabetes). Most of these health promotion approaches are aimed at achieving positive health behaviors at individual and community levels [95]. For example in Kigali, Rwanda physical activity is promoted among city residents by encouraging people to leave work early once in a week to engage in physical activity [96]. Such preventive approaches to NCD control targeting the behavioral risk factors are more cost-effective than treating the NCDs. A more concerted, strategic, and multi-sectorial policy approach is essential to help reverse the negative trends of NCDs in urban Africa.
