Harm reduction lobbyists will lead people onto the streets of South Africa if the government continues with its AIDS denialist-like stance on alternatives to cigarettes, thus punishing its most marginalised people. This was the fighting talk from tobacco control advocate Dr Kgosi Letlape at a global webinar hosted by the Vaping Association of South Africa (VAPSA) this week, writes Chris Bateman for MedicalBrief.
He was alluding to imminent legislation in South Africa outlawing some of the most effective harm reduction alternatives to lethal combustible tobacco products.
Letlape is past president of the Health Professions Council of South Africa, former chair of the South African Medical Association, and ex-president of the World Medical Association.
He was speaking on Tuesday 2 November in advance of next Monday’s virtual biennial Ninth Session of the Conference of the Parties (COP-9) to the World Health Organisation (WHO) Framework Convention on Tobacco Control(FCTC) in Geneva. COP-9 will set the tone and influence the global agenda on tobacco control.
An outdated global approach
FCTC policies were crafted well before current high-tech alternative nicotine devices came on the market. Tobacco harm reduction advocates argue that smokers should be encouraged to switch to safer alternatives, such as e-cigarettes or heated tobacco products or snus, which ease the path to abstinence by offering nicotine, without the terrible harms of cigarettes. It is widely acknowledged that it is cigarette smoke – not nicotine – that kills people.
The WHO is virulently against e-cigarettes, focusing on concerns around youth vaping, and has called on governments to regulate against them. This approach has long been criticised by the burgeoning global tobacco harm reduction lobby, as ignoring the public health imperative to help the world’s 1.1 billion smokers to quit.
The WHO approach nay be resulting in major collateral damage to smokers in low-to-middle-income countries (LMICs), where 80% of combustible tobacco is consumed, harm reduction advocates argue.
Most LMICs – often due to lack of capacity, lack of resources and cost – blindly follow the WHO lead. South Africa is no exception, either banning alternative nicotine products, hugely taxing them, or ignoring risk reduction approaches to public health.
Presumed incompetence
Letlape accused the FCTC of “presuming incompetence” among LMIC’s.
He used COVID-19 as an example, where many countries relied on vaccine evaluations done by the United States Food and Drug Administration and other regulators in the United Kingdom and European Union to fight the pandemic.
Yet some LMICs, like South Africa, are world leaders in innovative research responses to the pandemic.
Lashing out at South Africa’s short-sighted approach to tobacco control, particularly when it banned tobacco sales during the first COVID-19 lockdown, Letlape asked: “Why should our government buy into the WHO’s paternalistic tobacco view that we can’t think for ourselves? Why should we just be good disciples, following the law of Geneva?
“They should instead be promoting access to cessation-inclined and less harmful products when available,” he fumed.
He likened the SA government’s tobacco prohibition approach to apartheid’s Immorality Act or the more recent, vindictively-applied and punitive AIDS denialist policies, saying that they made no rational sense and caused more harm than good.
“Like during the pre-ARV days, we’ll stand up for our rights. The Constitutional Court proved its mettle during the AIDS denialist days,” said Letlape.
“We are now a global leader in the roll-out of ARV’s. It was civil society that took the initiative both times, and we’ll take to the streets again if needed when it comes to tobacco harm reduction. The evidence and health benefits are undeniable, overwhelming,” he added.
A flawed approach
Letlape said the SA government grouped cigarette smoking with alcohol in trying to relieve pressure on the healthcare system. Although combustible tobacco killed half of all users, alcohol had a far more dramatic and immediate negative effect on the healthcare system, contributing to road accidents, violence and all-round trauma and flooding ICUs with patients while hospitals desperately needed capacity during COVID-19 infection peaks.
“When we move to alternatives to combustible tobacco, a lot of the other harms are already reduced or eliminated altogether, and nobody talks about the benefits to others when people switch,” he said, adding that smoking cigarettes caused more than a dozen types of cancer, heart disease and respiratory conditions while second-hand smoke killed an estimated 1.2 million people worldwide annually.
As a physician, his advice to patients was always to quit smoking and, if they could not do so, to switch to a less harmful product such as e-cigarettes.
Government ‘addicted’ to tobacco tax revenue
“We will embrace smokers and say they are human too and should not be allowed to die,” Letlape said, adding that tax accounted for 70% of SA’s combustible cigarette prices, providing a major money spinner for government, which refused to see the far greater long-term healthcare and cost benefits of a pro-active harm reduction approach.
According to Asanda Gcoyi, chief executive officer of VAPSA, neither the South African National Health Department nor the SA National Council Against Smoking accepted invites to attend Tuesday evenings’ harm reduction pre-COP-9 webinar,
Drawing parallels between the battle against COVID-19 and the tobacco control protagonists, Letlape said that only when governments “drew in” the pharmaceutical industry and leading scientists was unprecedented progress made against the coronavirus.
Yet somehow the WHO and FCTC insisted on excluding tobacco multi-national companies and harm reductionist scientists and experts from the COP 9 summit.
“We Africans come from a background of being considered as sub-human. If you were competent in Africa, doors were always locked by a white government. But now they’re also being locked by black governments. We should not back off. We will hold our governments accountable, and the truth should reign.
“What would have happened with COVID-19 if scientists and governments had kept the pharmaceutical industry out? It is no different to the tobacco industry. We need to engage.”
UK leads with harm reduction
Criticising the WHOs decision-making and its lack of democratic behaviour, John Dunne, director general of the UK Vaping Industry Association, said the only hope tobacco harm reductionists had was to put pressure on their country’s elected representatives to demand transparency and a more evidence-based approach from the FCTC.
He added that e-cigarettes were not tobacco products and that it was debatable whether they fell within the FCTC’s remit at all.
The UK, with its world-leading progressive vaping and tobacco control policies, was a vital participant at COP-9, especially given that it was about to increase its funding of the FCTC by 30% over the next four years, and having now adopted a far more independent approach, post-Brexit.
Dunne called for the UK delegation to establish a COP working group on harm reduction and to oppose any position that equated vaping products with combustible tobacco products. He said Public Health England had clearly stated that vaping was 95% safer than combustible tobacco.
Clive Bates, former top strategy advisor to British Prime Minister Tony Blair in 2003 and Director of Counterfactual, a sustainability and public health consultancy, was asked by South African and former World Medical Association President, Dr Delon Human, why there was so much opposition to tobacco harm reduction.
“Battery technology has allowed electrical heating, which was not possible at the turn of the millennium. This allows for a much lower risk product and it’s an easier pathway than quitting completely. What’s not to like? So why are all these organisations, many of them Bloomberg-backed, feeding off one another? What’s not to like?”
Bates said his theory was that “cultural inertia” was to blame. “Their motto was: ‘We fight wars with big tobacco. This is what we do.’ Now the enemy is nicotine, and we must turn our gun turrets on the new thing and start blasting away.
“With their leadership, it’s also institutional inertia or self-interest in perpetuating their own existence. Their livelihoods depend on it and it is also about prestige. It’s a professional vocation propagated via research, activism and bureaucratic regulation, globally,” he added.
“Saying to them that something has come along that solves the problems you’ve been working your arse off on for the past 30 years – and does it more effectively – will obviously create a rejection of that idea. They simply say: ‘This is what we do, and this is who we are.’”
See also from the MedicalBrief archives
Global tobacco control ‘hugely outdated’ – Dr Kgosi Letlape
Confusion clouds FDA’s approach to e-cigarettes – POLITICO analysis
100 experts from 30 countries urge WHO to change tobacco harm reduction stance
Tobacco harm reduction – Patients before prejudices