Former secretary general of the World Medical Association Dr Delon Human has slammed SA’s tobacco lawmakers for likening tobacco harm reduction products to combustible tobacco. He says this is “totally contrary,” to the country’s hard-won human rights culture and violates consumers’ rights to accurate information.
Earlier this month, Cabinet approved the long-awaited Tobacco Products and Electronic Delivery Systems Control Bill for submission to Parliament, a crucial step in the government’s plans to further restrict the promotion and use of tobacco and nicotine-related products. The Bill also seeks to regulate electronic cigarettes, which do not contain tobacco and are currently beyond government control, reports Chris Bateman for MedicalBrief.
The new legislation, treats, for example, e-cigarettes (which global studies have shown to be over 90% less harmful), on a par with combustible tobacco. It also introduces plain packaging, removes designated smoking areas in restaurants, prohibits outdoor smoking in public areas, retailers from displaying cigarettes, and outlaws cigarette and e-cigarette vending machines. With the exception of the e-cigarette vending machine ban – Human commends all these measures and is in favour of reasonable health regulation of nicotine-based products.
Speaking on the fringes of the 5th Global Conference on Tobacco Harm Reduction in Athens last week, Human said that while he was supportive of SA’s new laws tackling combustible tobacco, lawmakers failed to differentiate it from tobacco harm reduction products which have drastically reduced non-communicable diseases, (such as lung cancer and heart disease), in countries which have adopted a more progressive, risk differentiation approach.
The South African physician and co-founder and director of the African Harm Reduction Alliance, added, “my main issue is the lack of differentiation on the basis of risk. If you’re going to regulate harm reduction products it must be risk proportionate – and that includes risk proportionate marketing, labelling, registration of ingredients and taxation. Instead, what we have is total disregard for the voice of the consumer by not providing them with accurate risk information. If you lump combustive with non-combustible products like oral nicotine or e-cigarettes, you’re simply aggravating the misinformation – and we in South Africa have always been strong on human rights.”
Human says the intended amendments to tobacco legislation are a clumsy and unrefined attempt to mitigate SA’s tobacco related mortality and morbidity.
Professor Solomon Rataemane, chairperson of the Ministerial Advisory Committee on Mental Health in South Africa and a tobacco harm reduction expert, told the conference that a 2021 survey of 7 245 households revealed that 12.7m adult South Africans (29,4%) used tobacco and that 8.3% used smokeless tobacco in that year.
The survey also showed that 65.7% of current smokers planned to or were thinking about quitting smoking, 40.5% made a quit attempt in the past 12 months, and 42.9% of smokers who visited a healthcare provider in the past 12 months were advised to quit smoking. The problem, however, was that there were no smoking cessation clinics in the public sector.
Tobacco Atlas, a partnership between Vital Strategies and Tobacconomics at the University of Illinois, Chicago, estimates that more than 42 100 South Africans die from tobacco-related diseases each year. The tobacco industry has an infamous track record, causing 8m global deaths annually, and is known for tax evasion, money laundering, racketeering and corruption, plus opportunistically targeting young people, especially in Africa. Globally it lobbies for less stringent anti-tobacco policies, using myriad front groups and tame politicians.
Human, however, believes the ‘big tobacco” industry argument is ‘getting tedious, because technological innovation has changed the face of global nicotine consumption.
“The whole ‘big tobacco’ thing is a cop out and a red herring. Yes, all stakeholders should declare any conflict of interest – that’s very important – but the point is to look at the consumer and to serve their best public health interest first. It’s not only public health interest but the individual’s health interest as well. If you compare e-cigarettes with the COVID vaccine; both are harm reduction, yet you’ll never see us withholding an effective COVID vaccine. It’s the same with tobacco harm reduction and its related tools,” he told MedicalBrief.
Asked to comment on the almost derailed global TB conference held in Durban earlier this month, (September), after media disclosures that the Philip Morris International-backed Foundation for a Smoke Free World had granted the conference organisers, the Foundation for Professional Development (FPD) R2m for research on how tobacco use affects people’s recovery from mild COVID over time, Human was phlegmatic.
“The more research that’s done, the better. As long as the research is good, I’m not too worried about the funding – but it should always be disclosed,” said Human, who is also president and founder of the Geneva-based Health Diplomats, a specialised health, nutrition, and wellness consulting group.
Both the Bill and Melinda Gates Foundation and Find, a global group distributing diagnostics for poverty related diseases, pulled out of the Durban TB conference when Bhekisisa revealed that the FPD had failed to disclose their controversial COVID research funding. The FPD’s MD, Dr Gustaaf Wolvaardt, pleaded ignorance of PMI’s involvement and said the FPD had a strict disclosure policy on all funding.
When MedicalBrief put it to Human that the Athens tobacco harm reduction conference and it’s four previous annual iterations featured several PMI-funded and BAT researchers which anti-tobacco lobbyists have consistently claimed reduces its legitimacy, he responded thus.
“The industry scientists are here. So what? We need multi-stakeholder dialogue and action. We talk to big pharma and big alcohol, so why not the tobacco companies? I’m absolutely in favour of conferences like this.”
Human said that as a physician in South Africa he’d spent “decades advising patients to quit smoking. I became frustrated with the low success rate. This included my own father and mother- it took me 20 years to convince them. Then I discovered the Swedish case study on snus (a nicotine tea-bag-like sack placed between the cheek and gum), which has reduced cigarette smoking prevalence there to two percent with the lowest non-communicable disease prevalence in Europe. I realised that smoking cessation, approached from a pure medical point of view, and the available nicotine replacement therapy were simply not good enough. If you look at the global scoreboard we’re still not winning. About 12 years ago I got to understand alternative smoke free nicotine products better – in particular e-cigarettes in the United States.”
He says he also spoke to adult smokers and consumers of e-cigarettes.
“It was actually a combination of medical frustration and respectful listening to consumers that changed my mind. I realised that the answer lies in tobacco control and harm reduction. Historically I’d also been involved in other fields of harm reduction like drugs and alcohol, and I realised the complementary and synergistic effect of harm reduction science and products in public health prevention and control campaigns,” he added.
Meanwhile, PMI's SA division is also lobbying government to ease rules restricting tobacco advertising for “smoke-free” like its iQos device, arguing it needs more scope to inform consumers about alternatives to smoking, and that because the devices were regulated the same way as cigarettes, it was difficult to educate consumers on the products.
The manufacturer of cigarette brands Marlboro and Chesterfield has previously said it aims to derive half its net revenue from smoke-free products by 2025.
“Heat-not-burn” products like iQos contain tobacco that is heated to a lower temperature than a combustible cigarette, and release vapour containing nicotine.
The devices, along with other alternatives to traditional tobacco products such as e-cigarettes, are at the centre of a fierce public health debate about their use and regulation, with proponents arguing they are safer than cigarettes and opponents worried about their long-term effects, particularly among the youth.
“Because these heated tobacco products are regulated like cigarette… it makes it difficult for consumers to know about (iQos), what it does, where (they) can find it, and the best way to make the switch (from smoking),” said PMI SA consumer experience director David Kadalie.
“If we want to make a meaningful change and impact the big numbers, we need to be able to make consumers aware and inform them. We are for regulation, but we need to have sensible regulation,” he told Business Day.
PMI introduced iQos to SA five years ago and it remains the only Sub-Saharan country in which the device is available. PMI SA aimed to convert 365 000 of the about 15m people who use nicotine-containing products to iQOs by 2025, said Kadalie, admitting its price put it out of reach of most South Africans.
His call for differentiated regulation for heated tobacco products echoes that by PMI director for external affairs Ondrej Koumal at the fifth scientific summit on Tobacco Harm Reduction, which took place in Athens last week.
He told Business Day that differentiated regulation and taxation could be used to reduce prices and incentivise consumers to use less harmful tobacco products, such as iQos.
Disclaimer: Chris Bateman, a freelance healthcare journalist and former news editor of the SA Medical Journal was sponsored by PMI to attend the 5th Global Conference on Tobacco Harm Reduction, in Athens, Greece. He was not in any way influenced on what stories to write or whom to interview.
See more from MedicalBrief archives:
PMI: Survey shows balanced approach needed for tobacco harm reduction
Tobacco harm reduction – Patients before prejudices
E-cigarettes: What we know and what we don’t – Cancer Research UK