South Africans puffed away frantically during lockdown, according to a recent local analysis, which also noted an associated increase in waterpipe/hubbly-bubbly use during 2021 – and right through the pandemic – compared with 2017/18 and increased use of the new non-combustible tobacco and nicotine products (TNPs).
The findings, wrote researchers K Kali and O Ayo-Yusuf from the Africa Centre for Tobacco Industry Monitoring and Policy Research in the SA Medical Journal, highlight the need to strengthen tobacco control legislation and support the passing into law of the proposed Tobacco Products and Electronic Delivery Systems Control Bill.
Tobacco use remains a serious threat to public health, responsible for 8m deaths globally every year and about 31 000 deaths per year in South Africa.
While combustible cigarettes and non-cigarette products (waterpipe/hubbly) smoking, still pose the greatest and most recognised harm, the introduction of TNPs like heated tobacco products and electronic cigarettes has increased access to various products with varying health risk profiles.
And although the global incidence of adult cigarette smoking has dropped since 1980, the increased diversity of and growing market for TNPs promoted as less harmful alternatives to conventional factory-manufactured cigarettes (FMCs) have resulted in recent increases in the prevalence of concurrent use of various TNPs (i.e, dual and polytobacco use).
SA has one of the highest rates of tobacco consumption in Africa. By 2018, the popularity and prevlence of combustible tobacco products, especially non-cigarette tobacco use like waterpipe/hubbly smoking, had increased significantly compared with 2010.
Data up to 2018 suggest that tobacco smoking was increasing in South Africa, but only limited information is available on the impact of the pandemic on the current pattern of use of TNPs, wrote the study authors.
The aim of their analysis was to assess trends in socio-demographic patterns in the use of TNPs and the extent to which these factors and non-cigarette tobacco use may explain possible changes in TNP use between 2017/18 and 2021.
Data from three waves (2017, 2018 and 2021) of the SA Social Attitudes Survey (total N=8 140) were analysed. The socio-demographic correlates of current daily and non-daily use of factory-manufactured cigarettes (FMCs), roll-your-own (RYO) cigarettes, waterpipe/hubbly, electronic cigarettes (ECigs), snuff (a smokeless tobacco) and any combination of FMCs, RYO cigarettes and waterpipe/hubbly (‘current smoking’) in 2017/18 (pre-pandemic), were compared with those for 2021 (during the pandemic).
Chi-square analyses and generalised linear models were used to compare the prevalence of TNP use between the two periods. A Blinda-Oaxaca decomposition analysis was also used to explore the roles of various socio-demographic factors, including any differences in the use of TNPs, that might explain any observed differences in smoking rates between 2017/18 and 2021.
Up in smoke
Tobacco smoking (all combustible tobacco products) among SA adults increased significantly, from 18.0% (95% CI 16.0 – 20.37) in 2010 to 27.6% (95% CI 24.3 – 31.1) in 2021.
And the use of snuff doubled between 2010 (3.1%; 95% CI 2.3 – 4.1) and 2021 (6.4%; 95% CI 4.9 – 8.5).
Use of e-cigarettes increased almost tenfold, from as low as 0.5% (95% CI 0.2 – 0.9) in 2010 to 4.7% (95% CI 3.3 – 6.5) in 2021.
Tobacco smoking in general was consistently higher among men than women of all ages. In 2010, smoking among men peaked in the 45-54 year age group, whereas among women it peaked in the 35-44 group.
However, in 2021, smoking among both men and women peaked in the 24-35 year age group.
In contrast to FMC smoking, for which there was no difference in prevalence between 2010 and 2021 among 16-24-year-old women, the prevalence of all forms of tobacco smoking was higher in 2021 than in 2010 for women in this age group.
All forms of tobacco smoking increased significantly from a prevalence of 22.4% (95% CI 20.4 -24.5) in the 2017/18 period (before the pandemic) to 27.6% in 2021 (during the pandemic). In particular, Mpumalanga and Gauteng saw significant increases in smoking prevalence after 2017/18.
The study authors said the fact that Gauteng was one of only two regions to record a significantly increased smoking prevalence during 2021 compared with 2017/18 may be related to more waterpipe/hubbly use, perceived especially among young adults as a way of coping with the economic and mental stress after the onset of the pandemic in 2020.
This coping mechanism may be particularly relevant to that age group, who were socially restrained by lockdowns at the peak of the epidemic in this most densely populated and urbanised economic hub of the country, home to a large proportion of 18-34- year-olds, and which had also recorded the highest cumulative number of Covid cases by the time of the 2021 survey.
The significant increase in smoking in Mpumalanga requires further investigation, but might be related to the increasing use of much cheaper RYO cigarettes for those who could not access or afford FMCs during the temporary ban, especially in this relatively rural province.
Nevertheless, it was worth noting, said the researchers, that the observed increased access to cheaper RYO cigarettes and waterpipe/hubbly by all population groups did not cancel out the significant decrease in FMC smoking observed among those who self-identified as coloured.
The significant reduction in the prevalence of all tobacco smoking in that segment is a welcome development, and may be associated with the fact that, compared with black Africans, this population group experienced disproportionately high tobacco-related mortality rates. It is possible that greater realisation of the health risk in these communities may have prompted people to quit smoking after the onset of the pandemic.
The suggestion that the increase in smoking observed in 2021 may be linked to economic and mental stress is supported by the fact that the present study also showed that in the controlled model, people who had lost their jobs (i.e. indicated they had been in paid jobs in the past) had a higher smoking prevalence than those who were currently employed, and that the prevalence in this group was even higher than among those who had never been employed.
The analysis noted that the fact that young adults, especially women, were increasingly smoking e-cigarettes and waterpipe/hubbly might also be related to mental stress, as reported cases of gender-based violence against women increased during lockdown, when they might have been forced to spend unusually long periods at home with their partners
Studies have suggested that women who experience violence may find relief in smoking, which could be especially relevant to the social nature of waterpipe/hubbly smoking.
Alternatively, the increase in the use of emerging TNPs by young women could be related to advertisements and targeted promotion of these products to young females on social media, resulting in changes in smoking norms.
A recent study of adolescents from 20 countries in Africa suggested that an increased level of reported exposure to tobacco adverts was positively associated with waterpipe smoking among girls.
The fact that these young adult women are of childbearing age and likely to spend time with children, as caregivers and therefore as role models, suggests potential serious public health problems in the future if culturally appropriate health promotion interventions are not targeted at this population group to reduce all forms of use of nicotine and tobacco products.
Study details
A decomposition analysis of socio-demographic factors and non-cigarette tobacco use as contributors to the change in smoking rates in South Africa between 2017/18 and 2021
K Kali, O Ayo-Yusuf.
Published in the SA Medical Journal in June 2024
Background
Trends data up to 2018 suggest that tobacco smoking was increasing in SA, but only limited information is available on the impact of the pandemic on the current pattern of use of tobacco and nicotine products (TNPs).
Objectives
To assess trends in socio-demographic patterns in the use of TNPs and the extent to which these factors and non-cigarette tobacco use may explain possible changes in rates of TNP use between 2017/18 and 2021.
Methods
Data from three waves (2017, 2018 and 2021) of the South African Social Attitudes Survey (total N=8 140) were analysed. The socio-demographic correlates of current daily and non-daily use of factory-manufactured cigarettes (FMCs), roll-your-own (RYO) cigarettes, waterpipe/hubbly, electronic cigarettes (ECigs), snuff (a smokeless tobacco) and any combination of FMCs, RYO cigarettes and waterpipe/hubbly (‘current smoking’) in 2017/18 (pre-pandemic) were compared with those for 2021 (during the pandemic).
Chi-square analyses and generalised linear models were used to compare the prevalence of TNP use between the two periods. A Blinda-Oaxaca decomposition analysis was also used to explore the roles of various socio-demographic factors, including any differences in the use of TNPs, that may explain any observed differences in smoking rates between 2017/18 and 2021.
Results
Current smoking increased significantly from 22.4% (95% confidence interval (CI) 20.4 – 24.5) in 2017/18 to 27.6% (95% CI 24.3 – 31.1) in 2021 (p=0.009). Smoking of FMCs did not change significantly overall between these two periods (20.1% v. 22.1%; p=0.240), except for a significant increase among those who self-identified as black African and a decrease among those who self-identified as coloured and those currently employed. However, the use of waterpipe/hubbly, ECigs, RYO cigarettes and snuff increased significantly. Women, individuals aged <35 years and black Africans had the largest increase in waterpipe/hubbly and ECig use. A decomposition analysis showed that increased waterpipe/hubbly and RYO use explained 52% and 15%, respectively, of the increase in smoking rates, while lower employment during 2021 compared with 2017/18 explained 15% of the increase in smoking rates during 2021.
Conclusion
The use of all TNPs continued to increase in SA, particularly among women and unemployed people. These findings have policy and practice implications for addressing socioeconomic disparities in tobacco-related diseases.
K Kali, BA Hons Psychology; O Ayo-Yusuf, BDS, PhD – Africa Centre for Tobacco Industry Monitoring and Policy Research, School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria
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