Building policy consensus on achieving a smoke free South Africa

Appropriate vaping legislation presents huge opportunity to save lives and cut national health spend

Johannesburg, 26 January 2016: In an attempt to build policy consensus on achieving a smoke free South Africa, a panel of experts gathered at Johannesburg’s Hyatt Regency Hotel on Wednesday 25 January 2017. Four health professionals presented a variety of views on the efficacy of vaping – the increasingly popular smoking of e-cigarettes – as a healthier alternative to the smoking of traditional tobacco cigarettes.

The FCTC Cop 7 conference held in Delhi in November 2016 saw South Africa’s Health department issue statements indicating its intention to adopt a ‘no compromise’ position on vaping and related products. These statements equated vaping with the smoking of tobacco cigarettes, expressing the Department of Health’s intention to regulate vaping accordingly.

Wednesday’s discussion provided South Africans a long-overdue platform to propose alternate positions on what is, globally, an advanced conversation. More importantly, the discussion highlighted the critical opportunity that South Africa has to reduce the harm of smoking by encouraging the use of disruptive vaping technology.

Dr Delon Human, co-founder of the Africa Harm Reduction Alliance (AHRA) and President of Health Diplomats, Clive Bates of Counterfactual and former Director of Action on Smoking and Health UK, Dr Kgosi Letlape, President of the Health Professions Council of South Africa (HPSCA) and Associate Professor Richard van Zyl-Smit, Head of the Lung Research Unit at the University of Cape Town Lung Institute and a consultant pulmonologist at Groote Schuur Hospital, contributed a variety of views.

While there was general consensus that vaping presented a safer alternative to smoking, the degree to which vaping was safer was contested. Vaping advocates generally concurred with Public Health England research that vaping was 95% safer than smoking tobacco cigarettes.  Associate Professor van Zyl-Smit, on the other hand, believed that there is enough clinical trial history to support these figures. There was also an inconclusive debate on whether health professionals should be advocating vaping as a healthier alternative to smoking. Equally contested was the efficacy – and advisability – of vaping to act as a gateway to quitting. Furthermore, “what might be considered a relatively safer alternative for smokers was not, however, ‘safe’ for passive smokers,” he added.

How South Africa chooses to develop vaping legislation would be critical in determining whether the country’s seven million smokers were provided the correct information on, and access to, affordable vaping products.

Associate Professor Van Zyl-Smit reminded the panel that since the World Health Organisation (WHO) had come out with a clear anti-vaping position, “health professionals and legislators needed to consider that vaping did not provide an alternative to smoking that was 100% safe.”

Dr Human, speaking from the perspective of a physician, argued that since those who smoke have a one out of two chance of dying from a smoking related disease, vaping provided smokers a, “get out of jail free ticket – by providing a real route out of tobacco smoking – or, at least, a way to reduce the harmful effects of smoking by 95%.”

Clive Bates reaffirmed that the Tobacco Working Group of the UK College of Surgeons reached consensus on vaping being 95% safer than smoking. This was important as, given public confusion around vaping, “there had been a clear and urgent need to provide physicians with the right tools to explain the relative risk of vaping correctly.” It was critically important that smokers and legislators did not squander the opportunity to save a billion lives globally – or forego the chance to reduce the burden of smoking-related diseases on national health budgets.

Dr Letlape added that smoking was an acknowledged health problem in South Africa with complex negative influences on HIV, tuberculosis and pneumonia. Smoking had profound implications for the country’s health profile along with the affordability of health. The country urgently required a “competitive, less harmful, alternative to tobacco smoking that was affordable and accessible to all LSM groups in South Africa.”

Dr Letlape argued that South Africa could not afford to be precious about the degree of safety or assume ideologically-based positions on affordable nicotine replacement that can save lives.

we should develop legislation aimed at making the experience of vaping safer, attractive and more accessible to existing smokers.

Dr Letlape referred to South Africa’s adoption of legislation promoting circumcision which, though it only reduced the chance of HIV infection by 50% per engagement, was nevertheless adopted as national policy on the basis that circumcision saved lives. Similarly, total abstinence presented a 100% effective strategy for the reduction of HIV infection. All other HIV control methods, such as the promotion of prophylactics and antiretrovirals, produce outcomes that are less than 100% effective. “This did not, however, prevent government from adopting legislation promoting prophylactics and antiretrovirals in the fight against HIV,” explained Dr Letlape.  Similarly, quitting tobacco smoking entirely provided a solution that was 100% safe. Since cold quitting was not possible for most tobacco addicts, however, “South African legislators should not deny the country’s smokers an alternative that was more effective than existing nicotine replacement therapies (NRTs).”

Mr Bates warned that applying a WHO ideologically-motivated, anti-tobacco framework to vaping, risked creating legislation that made vaping products unappealing to users, difficult to access, and ineffective as quitting mechanisms. This would provide the global tobacco industry with a massive advantage, “in effect amounting to the promotion of tobacco products, just as the world was faced with a new technology with the potential to entirely disrupt – and replace – the tobacco industry,” he explained.

Dr Human went on to argue that if South African legislators were to maximise this opportunity, “we should develop legislation aimed at making the experience of vaping safer, attractive and more accessible to existing smokers.”

Mr Bates reminded the panel of an October 2016 report by the UK Centre for Alcohol and Tobacco Studies (UKCTAS) indicating that, “the section on risks of second-hand exposure to ENDS aerosol provides no evidence that such exposures pose any material risks to bystanders.” Since vaping did not pose a passive smoking risk, legislators should resist the temptation to apply passive tobacco smoking legislation to vaping.

Separate studies from the United States and Europe supported the argument that where legislation sought to restrict access – by age, flavours or vapour device design or size, for example – levels of smoking increased. As such, “legislators needed to consider the unintended consequences of legislation, ensuring that legislation did not detract from the efficacy of vaping as a readily available, attractive, and affordable alternative to smoking,” said Mr Bates.

Associate Professor Van Zyl-Smit reminded the audience that vaping was a very new phenomenon. “Given all that we don’t know about the long term effects of vaping, it deserves separate legislative consideration.” The challenge then becomes, “how best to regulate vaping such that we include a public protection element,” he explained.

Dr Human concurred, adding that South African legislation needed to resolve four critical areas in; marketing, labelling, regulation and taxation. For example, while there was consensus that vaping should not target children or non-smokers, “guidelines should not prevent vaping from becoming an attractive and effective alternative to the smoking of tobacco cigarettes,” he explained. This also had implications for labelling and advertising. Legislation should not be so onerous that it limits the availability or increased the cost of vaping products. This would, detract from the effectiveness of vaping products as affordable, accessible and attractive alternatives to the smoking of tobacco cigarettes. “This would compromise the ability of vaping to truly disrupt tobacco’s hold on South Africa,” he said.

Despite the efficacy of vaping as a healthier substitute for tobacco, vaping advocates have made a conscious decision not to seek to promote vaping as a medically registered nicotine replacement therapy (NRT). “Classifying vaping as a NRT would require a protracted registration process and also dramatically increase the costs of producing, marketing and distributing vaping products,” said Mr  Bates. Diet Coke, for example, is not sold as a therapeutic medicine, even though consumers know that reducing sugar intake has therapeutic benefits.

While South African legislators are yet to engage with the full spectrum of positions as well as the existing science concerning the vaping versus smoking debate, it is important that the South African public are made aware of the huge opportunity that vaping offers smokers to embrace healthier lifestyles. It is equally important that South African legislators adopt a pragmatic approach to vaping. Such an approach should not limit the efficacy of vaping as a safer alternative to smoking or discount, “the potential to save lives and dramatically reduce the burden of smoking-related diseases on South Africa’s national health system,” concluded Kabir Kaleechurn, Director of Vapour Products Association of South Africa.