An estimated 13 million women in 37 sub-Saharan countries use tobacco in various ways, including snuff, which is common in South Africa. Picture: Reuters/Umit Bektas

The new Control of Tobacco Products and Electronic Delivery Systems Bill loses the opportunity to provide the millions of South African cigarette smokers with clear, unambiguous risk differentiation between tobacco and nicotine. 

Tobacco kills, but nicotine-based vaping products (e-cigarettes) can be a lifesaver. It is important for government to understand and communicate the difference accurately and responsibly to our citizens. 

It is an important moment for the South African government to provide risk-based regulations to minimise tobacco-related disease and premature death and maximise the potential of smokers being encouraged to quit smoking or switch to less harmful forms of tobacco or nicotine.
Imagine the approximately 9 million cigarette smokers of South Africa in one smoke-filled room. With the fire burning, the only way out is either to douse the fire, or to leave via the fire exit. 

Tobacco control has been trying to douse the fire, with limited success, for 40 years. Likewise, a small fire exit has long been available in the form of nicotine replacement quitting therapy. Not many smokers have used this exit, because it is a medicine and they don’t feel like patients. Now reduced risk tobacco and nicotine products offer an immediate, and more successful way out for smokers. 

It is not a totally safe option, but in comparison with the ongoing use of combustible cigarettes, it is much, much safer. It is the fire exit we have been waiting for!
Unfortunately, the Bill folds these nicotine products into the tobacco category, and subjecting the category to an advertising ban, display ban, plain packaging, graphic warnings and smoke-free laws. This will amount to a de facto ban, block the fire exit and millions of South African cigarette smokers won’t switch to less harmful alternatives. Even worse, it could become the “Big Tobacco Protection Bill”. Meaning that if the Bill were to lead to the decimation of the E-cigarette category, by default it would protect the cigarette industry and the maintenance of the status quo. 

It needs to be noted that the SA government has already successfully employed harm reduction in other fields, such as HIV / Aids, road safety and intravenous drug use. Here government programmes have addressed high-risk behaviour (eg unsafe sex), through strategies, education and products to facilitate change to lower-risk behaviour. 

In HIV / Aids, government policy has not been to tell people to stop sex, in order to avoid HIV. Rather, it has instituted a wide-ranging programme of ensuring education and access to condoms for safer sex. Likewise, e-cigarettes are not necessarily safe, but safer than the ongoing use of combustible tobacco. 

The gold standard in tobacco control remains to quit smoking. However, it is well-known that even with best practice cessation methods and products, the cessation success rate is less than 5%. Here tobacco harm reduction can be used as a mutually reinforcing and complementary tool. It addresses the fact that most of the harm related to tobacco is because of COMBUSTION, and the smoke it produces. People smoke for the nicotine, but they die from the tar. 

If the tar can be minimised or eliminated, harm is reduced significantly. In the past, there were few harm reduction products available. However, since 2010 several non-combustible tobacco and nicotine products have become available, such as vaping products (e-cigarettes), heated tobacco products, or smokeless nicotine-based snus. It is noteworthy that the increase in use of these products, have coincided with significant declines in cigarette smoking, especially in the UK, US and Japan.

The World Health Organisation’s Framework Convention on Tobacco Control (FCTC) supports harm reduction. The FCTC Article 1(d) states that “tobacco control” means a range of supply, demand and harm reduction strategies that aim to improve the health of a population by eliminating or reducing their consumption of tobacco products and exposure to tobacco smoke. 

It is regrettable that the draft Bill does not explicitly address tobacco harm reduction in terms of definition, description, individual health, risk-proportioning, evidence based, product definition and the overall regulatory intent. 

The conflation of combustible tobacco products and non-combustible nicotine products in the bill, is clearly out of step with other national agencies. Other countries have already shown the way with proportionate, risk-based regulation of tobacco and nicotine products, with most encouraging results. 

In the United Kingdom, regulations have been designed to help cigarette smokers switch to less harmful vaping products (e-cigarettes). Public Health England has gone so far as to publicly advertise that cigarette smokers should switch to e-cigarettes, on national prime-time television. 

Other UK agencies have also publicly recognised tobacco harm reduction and the potential benefits of e-cigarettes, such as the British Medical Association, UK National Institute for Health and Care Excellence, Cancer Research UK and the Faculty of Public Health. 

The acceptance of tobacco harm reduction is not limited to the United Kingdom. In the United States, the FDA approach is to restrict tobacco, while encouraging smokers to move to less harmful nicotine-based products. In the European Union, often considered the home of red tape and bureaucratic over-reach, a recent study suggested that as many as 15 million smokers in member countries had either quit or cut back on their cigarette use thanks to the ready availability of nicotine-based vaping alternatives. 

The article by Patricia Lambert (“Time to join the global movement to stub out the tobacco epidemic”, Sunday Times, 2 September 2018) calls for the protection of children from tobacco and nicotine products, which all can agree with. But rather misleadingly, throughout the article tobacco and nicotine is equated, even implying that nicotine-based products are “deadly”. In South Africa, human rights matter. 

This includes the right to seek and receive accurate information concerning health issues. This right is especially relevant for consumers of combustible cigarettes, seeking ways to stop these products or to switch to less harmful nicotine-based alternatives.

Through the Bill, the government has an opportunity to prevent tobacco-related disease and premature death. They can ascertain that the most harmful products, ie cigarettes, are subject to the most strenuous regulation, while less harmful nicotine-based products are regulated based on risk and communicated as such. This kind of progressive, risk-based, proportionate regulation of nicotine products will facilitate that smokers can either quit, or switch to less harmful nicotine products.
It could become one of the most important breakthroughs in South African public health this century.

Dr Human is a South African physician, involved in tobacco control and harm reduction for the last 25 years (in South Africa and globally). He is the President of Health Diplomats, founder Director of the Africa Harm Reduction Alliance (AHRA), former Secretary-General of the International Food and Beverage Alliance and the World Medical Association. 

This perspective on the importance of risk differentiation between tobacco and nicotine, and the accurate and fact-based communication of science to encourage tobacco harm reduction. 

The Sunday Independent