The 16-year-old Framework Convention on Tobacco Control (FTCT) of the World Health Organisation – signed by 180 countries including South Africa and many other African nations – is wholly inadequate to address the now ubiquitous tobacco harm reduction market, says Dr Kgosi Letlape, president of the Africa Medical Association.
He and other African clinicians shared their experiences on advocacy and policies around tobacco harm reduction on the continent, at the 4th Scientific Summit on Tobacco Harm Reduction: Novel products, research and policy, writes Chris Bateman for MedicalBrief.
People in low- to middle-income countries have no or very limited access to relatively expensive alternative nicotine delivery products that have been shown to help cigarette smokers quit. People are also misinformed or ignorant of the major health benefits, while their governments’ tobacco control policies are dismally inappropriate.
Many African countries blindly follow the WHO’s outdated FTCT in tobacco legislation, Letlape says. This means their populations are way behind those in more developed countries, with many more people still suffering and dying from avoidable diseases related to combustible cigarettes.
The cyber-summit, held on 29-30 September and attended by thousands of delegates from around the globe, also heard from North African physicians that people with mental health issues – which experts say are often linked to abuse of tobacco and other substances – suffer a double burden, with smoking cessation being even harder.
Africa – Cheap cigarettes, few alternatives
Dr Kgosi Letlape is a past president of the Health Professions Council of South Africa, former head of the South African Medical Association, ex-president of the World Medical Association, and current president of the Africa Harm Reduction Alliance, which works to create awareness and educate people about the need to reduce harm and promote well-being
He said the FCTC was clearly focused only on combustible tobacco products, especially cigarettes. “We need the framework amended to be appropriate for the products available today – you can’t just do a cut and paste of the FTCT to non-combustibles. It just doesn’t work and is inappropriate for e-cigarettes, heat-not-burn products, snus, chewing tobacco and others.
“We need to advocate for appropriate regulation. One of the key issues for Africa is that cigarettes are cheap. We need to ensure governments don’t make alternatives to combustion unaffordable to ordinary people.”
Letlape said that in spite of South Africa being one the earliest FTCT adopters, seven million of its citizens still smoke tobacco, a reduction from a 30% to 40% smoking prevalence in 2006 to about 17% currently. Many, including lung cancer survivors, quit – only to find themselves smoking again within three months.
While the FTCT was a “great tool” for nations to adopt when it came to combustible cigarettes, it was useless in addressing the harm reduction alternative products that had burgeoned since 2010.
“When the FTCT was adopted, there were no alternatives to combustibles except nicotine replacement therapy such as gum, patches, sprays, inhalers and lozenges,” said Letlape.
Professor Michael Russel – a British psychiatrist, considered the father of harm reduction – kick-started the alternative tobacco products industry with his much quoted comment that “people smoke for nicotine but die from the tar”. Now there is an array of alternatives, driven by new technology.
Letlape was one of five people enrolled earlier this year by the Philip Morris International-sponsored Foundation for a Smoke Free World to produce the report Reigniting the Fire against Smoking.
Wayward smoking prevalence curve
He said smoking prevalence worldwide in the late 1950s stood at about 50%. After the landmark 1964 United States Surgeon General’s report on co-morbidities and smoking-related death rates – cigarettes were killing one in two smokers – there had been a marked decline in smoking globally.
“But then paradoxically, and almost coinciding with the FTCT, global smoking numbers increased from 999 million in 1995 to 1.1 billion today with a decline in quitting rates in developed nations and even more so in low- and middle-income countries that adopted the FTCT.”
Letlape said access to alternative non-combustible products was key for all vulnerable groups, but particularly so in Africa and other developing regions where proper regulation, access to and promotion of affordable alternatives to cheap cigarettes were sorely needed, and misinformation and disinformation ran rampant.
“Smokers matter. COVID has taught us that those who fail to base their approach on science are called anti-vaxxers…misinformation on tobacco is actively propagated by the WHO – for example more than 70% of people think e-cigarettes are more harmful than cigarettes.
“We need new regulations based on modern science and the relative harms caused by alternative nicotine delivery products,” Letlape argued.
It was ironic that chewing tobacco had existed in Africa for centuries yet was not encouraged as an alternative to cigarette smoking by African governments.
“Our governments need to understand that the FTCT is great for combustibles, but wholly inappropriate for anything else not based on combustibles like snus, which has been a total game-changer in Sweden,” he added. Snus use is attributed to 30% of Swedish male smokers quitting, and tobacco related mortality in Swedish men is the lowest in Europe.
Depression linked to smoking
Moroccan psychiatrist Dr Imane Kendili told the session that in Moroccan public hospitals a strong link has been found between depression and nicotine use in patients. A nicotine-induced increase in dopamine and a concurrent drop in serotonin in neural pathways contributes to depression, anxiety and other mental illnesses, including obsessive behaviour.
“We know that people with mental diseases are not always able to hear you or speak to you about their addictions. They can talk to you about their depression, anxiety or insomnia – but when you talk about cigarettes, they just look at you and say, ‘but it’s my best friend!’.”
Kendili added that her patients would then outline all their “far worse problems, including their family and work environments”.
One quitting experiment she conducted with 43 people with mental health issues resulted in 15 of them switching to heat-not-burn alternative tobacco products.
“We especially need to persuade those with co-morbidities to switch to alternative products such as e-cigarettes – but we obviously need longer and more intensive treatment,” she said, adding that it was difficult to tell whether mental illness led to smoking or vice versa.
Her work has shown that it is easier to ration consumption using alternative nicotine devices than it is with cigarettes.
Kendili warned that in many African countries, smoking cigarettes is a “symbol of modernity”. Ironically, African governments are increasingly using harm reduction strategies in sex work, substance and alcohol abuse, yet the promotion of available alternatives to smoking lags way behind.
Multi-substance abuse – A problem
Dr Haifa Zalila, a psychiatrist at the medical school at the University of Tunisia who works in a mental hospital in Tunis, said smoking prevalence was two to four times higher in patients concurrently using other substances, with far higher relapse rates after quitting cigarettes.
“The problem with the abuse of multiple substances is that there is neurobiological modification due to repeated use – the reward system is disturbed and there is prefrontal cortex impairment which impacts on the possibility of quitting,” Zalili explained.
Using the Subjective Units of Distress Scale (SUDs) – a tool for measuring the intensity of distress or nervousness in people with social anxiety – the medical school researchers compared people with psychiatric disorders to those with substance abuse disorders.
The substance abuse group scored more than 80% higher than the group with psychiatric disorders. Alcohol and cannabis were the most frequent substances concurrently used by tobacco smokers – and significantly increased nicotine cravings.
Zalila recommended a unified harm reduction approach to reduce SUD scores and tobacco addiction, saying this would substantially mitigate overall health risks.
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