The South African Medical Research Council (SAMRC) has highlighted some new in-depth data from the first Global Adult Tobacco Survey conducted in South Africa in 2021 (GATS-SA) supporting key measures in South Africa’s proposed Control of Tobacco Products and Electronic Delivery Systems Bill, saying it should be passed with urgency. Lead investigator and specialist scientist within SAMRC Alcohol Tobacco and Other Drug Research Unit, Dr Catherine Egbe, discussed results including South Africa’s high tobacco prevalence, secondhand smoke exposure and youth e-cigarette use in light of five key principles of the Bill, recommending further measures that should be taken to turn the tide on growing nicotine addiction in South Africa.
Overall, GATS-SA shows that 30.3% adults in South Africa are smoking, using smokeless tobacco and/or electronic cigarettes, the highest of all countries in the region that have completed the survey. The overall prevalence of manufactured cigarette use is 23.4% (38.3% men; 9.5% women). The highest prevalence of e-cigarettes and emerging products was in the 15-24 age group, an alarming statistic for harmful products. “The bill contains five key measures that will have a great impact on tobacco and e-cigarette usage in South Africa. Each of these is well supported by the data,” Egbe said.
Measures in the Bill include:
1. SMOKE-FREE PUBLIC PLACES
When it comes to exposure to smoke, the Bill will require 100% smoke-free indoor, and certain outdoor, public places. This is essential as many South Africans are exposed to second-hand smoke, says Egbe.
GATS-SA shows that 11.2% are exposed to second-hand smoke at work (7% are non-smokers) and 18% at home (9.6% are non-smokers). Women are mostly exposed at home from their partners, according to Egbe, while very few have the power to make their homes smoke free.
An alarming 74.4% of people are exposed at bars, tavern, pubs, shebeens or night clubs, 10.8% at restaurants and 5.8% at government buildings, which are supposed to be smoke free. 3.8% are even exposed at healthcare facilities
Egbe highlights that a concerningly high percentage of non-smokers are exposed at educational institutions. Of the 16% exposed to second-hand smoke in Tertiary Institutions, 46.3% are non-smokers. While 20% of people are exposed in schools in schools, 35.2% are non-smokers.
“93% of South Africans believe that smoking can cause serious illnesses, and the same percentage believe that breathing other people’s smoke can cause serious illnesses in non-smokers,” says Egbe. “Overall, there is overwhelming support for the bill, says Egbe, with 9 out of 10 – 88.4% – agreeing there is a need to ban smoking in indoor workplaces and public places.”
2. PLAIN OR STANDARDIZED PACKAGING FOR TOBACCO & NICOTINE PRODUCTS
80% of smokers say they notice current textual health warnings on cigarette packs, but less than 40% said seeing current warnings would make them think of quitting.
When it comes to hookah, most hookah smokers don’t even see the packs. Less than half say they noticed health warnings, and 19% said they would think of quitting based on current packs. Smokeless tobacco showed the same ratio, with only 52% noticing warnings and 25% saying the warnings made them think of quitting.
“What we have is not effective,” says Egbe. “We need more to encourage people to quit and stop people starting. 67% of smokers agree that textual health warnings would not stop them from smoking, while 58% said graphic health warnings, showing the health consequences of tobacco use, would encourage them to quit. This tells you that the plain packaging and graphic warning policy can help and is supported.”
3. REGULATING ELECTRONIC CIGARETTE USE
Emerging products including e-cigarettes and hookah are mostly used by younger age groups – with the highest percentage usage of e-cigarettes is in the age 15-24 category at 3,1% (overall prevalence is 2.2%), while 7.1% of this age group are using hookah.
Alarmingly, 21% of people have been using these products for more than two years, says Egbe. “While e-cigarettes are positioned as a smoking cessation aid by the industry, this wasn’t always the case. When they were going to be brought into the country, the Department of Health tried to stop them. In court documents, industry clearly stated that these products will not serve as cessation aids, and they are not going to be marketed as such. Now, when the department is trying to regulate the product, they are saying that they are smoking cessation aids. In South Africa, medicines are regulated by SAPHRA. So, if you want to present these products as cessation aid, get them certified, pass through the normal procedure. Even the normal nicotine patches that is available over the counter went through that procedure.”
Egbe says we have been contaminated with misinformation from the electronic cigarette industry. “When e-cigarettes are marketed to smokers, they simply want them to switch addiction. That is worrying. We want them to quit for good. When you quit tobacco, you should become free from nicotine as well.”
4. REMOVAL OF POINTS OF SALE ADVERTISEMENT AND MARKETING
Egbe says it is not coincidental that younger people are the biggest noticers of tobacco promotion, at 37% in the 15-24 age range. Egbe highlights that in the UK and other countries, tobacco products are not allowed to be on display. “When you want to buy cigarettes, you don’t see them. They are in a cupboard, you only see the price list. This is what we need in South Africa, and this is what the Bill wants to make happen.”
When it comes to e-cigarettes, regulation of advertising is critical. “We’ve all seen the prominent, brightly coloured displays of e-cigarettes in mall, kiosks and stores. You don’t see cigarettes displayed like this, it is not allowed,” says Egbe. “However, because the current law doesn’t include e-cigarettes, the industry exploits this legislative vacuum. The youth is clearly their market.”
5. REMOVAL OF VENDING MACHINES
Tobacco products are dangerous and should not be accessed by underage people, says Egbe. Vending machines further serve as display advertising, that all ages can access. These products should not be associated with chips and candies as you see happen with the display in vending machines.
Further to the measures in the Bill, Egbe called for better support for smoking cessation using evidence-based approaches. According to GATS-SA, about two thirds of smokers want to quit, while about 40% had made quit attempts in the last year. When smokers were asked what methods they tried to use to quit, almost 81% said without any assistance, while 4% said they use medication, almost 3% said they use counselling and 2.7% said they tried e cigarettes.
She highlighted the need to protect young people from being targeted, saying the statistics on tobacco use initiation call for sober reflection. Most young people between the ages of 15 and 24 (77.1%) purchased their cigarettes from Spaza shops and kiosks. “GATS-SA shows that almost 75% start smoking before they can really make the distinction between what is addiction and what is not. 18% start before they are 15, and 43% by 16. We cannot have young people who are still trying to figure themselves out being introduced to an addictive substance.”
Taxation is another widely supported tobacco control measure, with 73% of people supporting tax increments. “Tax increases are shown to lead to a decline in prevalence,” says Egbe. She further said that in South Africa, while R12 billion is contributed through taxes, R42 billion is lost annually through healthcare costs and lost productivity. “The tobacco industry takes far more than it gives. Also, there is no amount of money that can buy human lives.”
Egbe says that in line with the World Health Organisation Framework Convention on Tobacco Control (FCTC) guidelines, South Africa now has up-to-date and quality data to monitor tobacco use. “Insights from GATS-SA are particularly important at this time, further reinforcing the need to pass the Control of Tobacco Products and Electronic Delivery Systems Bill, and also providing benchmark data that will enable us to monitor its impact in the future.”
Leonce Sessou, Executive Secretary of the Africa Tobacco Control Alliance (ATCA) concluded the seminar by
congratulating the SAMRC research team. “This is what we need for advocacy. With no evidence, it would be difficult to support the implementation. South Africa is known as the most influential country in Sub-Saharan Africa and a driving force in the African Union. The lessons learnt from the legislative process will be key. You have our full support and we join hands with Civil Society in South Africa. We will be there to share what you have learnt with other parties in the region. The survey findings reveal that it is urgent for South Africa to pass the bill. Let’s join hands and get this done as soon as possible, not tomorrow, but now.”