The public health stakes and battle over tobacco regulation in Kenya

In her mid-20s, Alice began struggling to breathe. She was coughing and, at times, collapsing. Her first diagnosis was tuberculosis, and she took TB medication for six months.

But the swelling on her neck and the coughs did not disappear.

Further tests eventually revealed a rapidly growing cancerous tumour near major blood vessels in her neck. Alice underwent surgery followed by chemotherapy.

Her treatment has cost her family more than Ksh.2 million, with additional expenses continuing through follow-up appointments, tests and medication.

“There has been a tremendous change. In as much as I went through that pain, I can say the treatment was worth it," she says of her journey. 

Alice’s cancer journey is separate from her history of tobacco and substance use. There is no evidence presented here to establish that her tobacco use caused her cancer.

Years before her diagnosis, during a difficult period in her life, smoking had become part of her routine. She smoked cigarettes, vaped, used cannabis and drank alcohol.

At the time, she says, the substances offered an escape from stress.

“I needed someone to talk to. I had a rough time by that time,” Alice says.

What began as an attempt to cope gradually became part of her daily life.

“There was no time I never used drugs until I started realising the harm,” she recalls.

Her experience provides a personal entry point into a much wider debate facing Kenya: how should the country regulate tobacco and newer nicotine products while balancing public health, consumer interests and the concerns of businesses?

What Tobacco Smoke Does

Dr Mercy Maina, a toxicologist and pharmacologist and founder of Toxicology Experts, says tobacco smoke contains a complex mixture of toxic substances, including tar, carbon monoxide, formaldehyde, benzene and heavy metals.

She says repeated exposure can damage cells and DNA, while inflammation and damage to lung tissue can contribute to respiratory disease. Tobacco use is also associated with cardiovascular disease and several cancers.

Nicotine adds another layer.

Dr Maina says nicotine acts on the brain’s reward system, triggering dopamine release and creating a reward loop that can make tobacco use pleasurable. With repeated exposure, the brain can adapt to nicotine and begin to crave it.

“The brain rewires itself to crave nicotine, leading to dependence,” she says.

She adds that alcohol and nicotine can reinforce patterns of use for some people, making stopping more difficult.

When Addiction Affects Families

For Angeline Gituto from Nyeri County, the consequences of addiction were felt throughout her family.

Her uncle was an electrical engineer with a job, a family and what relatives describe as a promising future. According to the family, his tobacco use was later accompanied by heavy alcohol consumption and other drug use.

Over time, he became withdrawn, neglected responsibilities and eventually lost his job. His wife and child were left without his support.

The family spent money seeking psychiatric treatment and meeting his daily needs.

“We have faced stigma and public ridicule because of his addiction,” Angeline says.

Her experience illustrates how substance dependence can affect more than the individual. It can affect employment, relationships, household income and the mental health of relatives.

A Changing Nicotine Market

The debate is becoming more complicated as the nicotine market changes.

Consumers can now access conventional cigarettes alongside vapes, nicotine pouches, heated tobacco products and other nicotine products. There are also nicotine gums, lozenges, inhalers and sprays, many of which are used in smoking-cessation programmes.

But Dr Maina says newer products should not automatically be considered harmless alternatives.

Vapes may avoid the tar produced by burning tobacco. Still, their aerosols can contain substances such as aldehydes- toxic chemicals that can be produced when tobacco, shisha tobacco, or other materials are heated or burned- metals and ultrafine particles- extremely tiny airborne particles, generally less than 0.1 micrometres (100 nanometres) in diameter.

Nicotine pouches do not produce smoke, but can deliver significant amounts of nicotine and sustain dependence. Heated tobacco products reduce combustion but still expose users to nicotine and other chemicals.

“Conventional cigarettes remain the most toxic overall, but newer products are not risk-free,” Dr Maina says.

Battle Over Regulation

The regulatory challenge is therefore becoming more complex: how should Kenya distinguish between products with different exposure profiles while preventing new pathways to nicotine dependence?

It is against this backdrop that Kenya is debating new rules for tobacco and nicotine products.

The Tobacco Control (Amendment) Bill, 2024, sponsored by nominated Senator Catherine Muyeka Mumma, seeks to regulate emerging nicotine products, including vapes and oral nicotine pouches.

The proposed legislation has drawn concern from sections of the business community.

Businesses under the Pubs, Entertainment and Restaurants Association of Kenya (PERAK) are calling for nationwide public participation on the Bill, arguing that physical forums are necessary to capture the views of businesses, consumers and other stakeholders.

PERAK National Chairman Michael Muthami says businesses support regulation but want an inclusive process. He says proposed flavour restrictions could fuel an illicit market, while county licensing requirements could increase operating costs.

It is not whether nicotine products should be regulated. It is also about compliance costs, enforcement and whether restrictions could have unintended consequences.

The Shisha Question

The debate has also been reignited by a court decision lifting the ban on shisha use in Kenya.

The decision has drawn mixed reactions from tobacco-control advocates and members of the public. Some residents in Kakamega County have expressed disappointment, saying they remain concerned about the possible health implications of shisha use.

Kenya Tobacco Control Alliance (KETCA) National Chairman Joel Gitali has criticised the development, accusing senior government officials of undermining efforts to control tobacco and substance use.

His position reflects concerns among public-health advocates who argue that regulation should prioritise preventing harmful exposure and dependence, particularly among young people.

But the legal challenge to the shisha ban illustrates another dimension of public-health regulation: laws must be clearly drafted, legally sound and capable of surviving judicial scrutiny.

The question is therefore not simply whether shisha should be permitted or prohibited.

It is whether Kenya’s regulatory framework provides a clear, evidence-based and enforceable way of protecting public health.

Beyond the debate over which products should be regulated, tobacco-control advocates say another challenge lies in how existing laws are implemented.

Gitali said efforts to control tobacco use have been weakened by what he described as interference by some tobacco companies in the work of tobacco-control organisations and government agencies.

But his comments raise an important accountability question: what happens when laws exist on paper but implementation is weak?

Gitali says the challenge is not only passing laws but ensuring they are implemented consistently.

He also raised concerns about protecting children and adolescents, saying the government should do more to enforce laws intended to prevent people under 18 from accessing tobacco products.

A law may prohibit the sale of tobacco products to minors. However, its effectiveness ultimately depends on enforcement, monitoring, public awareness and whether young people can still access the products despite restrictions.

Prevention must begin with information

He is calling for stronger tobacco-health education in learning institutions, with health professionals given opportunities to engage directly with students about the potential risks associated with tobacco and nicotine use.

This is relevant as Kenya’s nicotine market becomes more diverse. Young people may encounter cigarettes alongside vapes, nicotine pouches and other products that are marketed or perceived differently.

Understanding what attracts young consumers, how they obtain these products and what information they receive is therefore an important part of the regulatory debate.

But education alone cannot carry the burden of tobacco control.

“Some of these products look like pens, others like lipstick or perfume, making it difficult for parents and teachers to know what children are using,” says Mary Muthoni, the Principal Secretary for Public Health and Professional Standards.

This is where the competing interests converge.

The Economics of Tobacco

The regulatory debate also comes at a time when the economic costs of tobacco use are receiving greater attention.

The cost of tobacco is not limited to what consumers spend at the point of purchase.

For people who develop tobacco-related diseases, treatment can involve diagnosis, medication, hospitalisation and long-term care.

Families may face lost income and unpaid caregiving, while employers can experience lost productivity. Health systems face additional demand for services.

These costs are less visible than tobacco tax revenues, investment figures or the economic value of the industry, but they are borne by households, communities and governments.

Public-health experts say tobacco companies are increasingly using economic and legal arguments to challenge regulations designed to reduce tobacco-related harm.

During a continental meeting organised by the Africa Tobacco Control Alliance, public-health researcher and tobacco-control advocate Dr Peter Magati said health regulations may be framed as economic violations, including claims involving trademarks and intellectual property, discriminatory treatment, trade or market access, and investment rights or expected returns.

“The common thread across all four mechanisms is that, in every mechanism, the industry translates a health regulatory action into an economic rights violation,” Dr Magati says.

“The public health has been responding with health arguments. The industry has been responding with economic arguments,” he adds.

Dr Magati argues that public-health advocates therefore need independent evidence to demonstrate the economic costs of tobacco-related disease, including lost income, treatment costs and unpaid care.

The WHO Framework Convention on Tobacco Control Article 5.3 Toolkit guides protecting public-health policies from tobacco-industry interference.

Dr Magati also argues that health ministries should have a stronger role in trade negotiations so that health considerations are not separated from economic policy.

Who Pays?

Businesses want meaningful participation in law-making and warn about unintended economic consequences. Public-health experts want stronger safeguards against nicotine dependence and harmful exposure.

Consumers need clear information about the products they use. Policymakers must weigh the costs of both regulation and tobacco-related harm.

For Alice, the cost of serious illness is not an abstract economic calculation. It is found in hospital bills, chemotherapy, medication and the disruption treatment has brought to her life.

Her cancer is not being attributed to tobacco use.

But her history of smoking and nicotine use is part of the wider story of dependence and the health risks that Kenya’s tobacco-control framework is attempting to address.

For Angeline, the consequences of addiction have been different but equally personal: lost employment, treatment expenses, stigma and the loss of financial and emotional support.

Their stories show how substance dependence and serious illness can impose costs beyond the individual.

As Parliament considers the Tobacco Control (Amendment) Bill, the central question is no longer simply whether tobacco and nicotine products should be regulated.

It is how Kenya can protect public health while ensuring that regulation is evidence-based, legally sound, enforceable and informed by those who will be affected.

Because the cost of tobacco does not appear in one place.

Some of it is found in tax revenues. Some in business accounts. Some in lost productivity. Some in household budgets dealing with addiction. And some in hospital bills.