SA’s The Prevention of and Treatment for Substance Use Disorder Policy: A Lesson to Learn for Tobacco Harm Reduction

South Africa has a long-standing tradition of adopting harm reduction strategies to address public health crises. From the fight against HIV/AIDS to needle exchange programs, harm reduction has been pivotal in saving lives and improving health outcomes. As the country now faces the ongoing challenge of tobacco-related illnesses, it is imperative that the government embraces harm reduction in the realm of tobacco control. By doing so, government can significantly reduce smoking-related diseases and deaths, ultimately benefiting public health and saving countless lives.

South Africa’s approach to reducing HIV/AIDS prevalence is a prime example of how harm reduction can transform public health. The introduction of mass education campaigns, availing condoms in public places, needle exchange programs, and the promotion of safe sex practices have been instrumental in reducing the transmission of HIV. While condoms are not perfect, they are safer than no condom sex. Government knows that stopping people, especially young people from having sex is difficult, but through education, they can be educated about the consequences of unsafe sex practice and making condoms easily accessible.

The Prevention of and Treatment for Substance Use Disorder Policy by the Department of Social Development prevents a model to be followed by all of government in ensuring better public health outcomes in addition to legislation. The policy is underpinned by three pillars, prevention, law enforcement, and harm reduction. The first pillar is aimed at preventing the onset of substance abuse or dependence as well as eliminating or reducing the effect of conditions conducive to the use of dependence forming substances. The second pillar is aimed at reducing the supply of both legal and illegal drugs. Lastly is the Harm Reduction Pillar which includes treatment of substance use disorders and related activities aimed at reducing harm caused by use and abuse of substances in communities. It involves reducing the damage caused by substance abuse to individuals and communities.

Tobacco use remains the leading cause of preventable death in South Africa. The Global Adult Tobacco Survey 2021 highlights that tobacco use remains elevated, sitting at 29.4% overall (12.7 million adults), with 41.7% of men, and 17.9% of women currently using tobacco. Smoking-related diseases, including lung cancer, Chronic Obstructive Pulmonary Disease (COPD), and heart disease, place a significant burden on the healthcare system and contribute to premature mortality.

A tobacco harm reduction strategy in the spirit of the Prevention of and Treatment for Substance Use Disorder Policy, will offer a complementary approach to tobacco control legislation. By adopting similar pillars to the policy, government can help smokers reduce their exposure to harmful substances and ultimately quit smoking altogether, whilst discouraging young people from accessing the products and dealing with the illicit market. Vaping has been proven to be a valuable harm reduction tool in the fight against tobacco smoking. Scientific evidence from institutions such as Public Health England, UK Royal College of Physicians and Cochrane Library Review, support the potential of vaping in playing a crucial role in harm reduction and smoking cessation.

Countries which have embraced harm reduced alternatives to smoking such as the United Kingdom (UK), Sweden, and New Zealand (NZ) provide ample evidence on how harm reduction – when embraced in the realm of tobacco control – can be effective in reducing smoking prevalence and ultimately, reducing smoking-related deaths.

However, despite overwhelming evidence supporting the success of harm reduction strategies in dealing with addictive behaviours, South Africa’s tobacco control policy remains predominantly focused on punishing smokers. This approach, while well-intentioned, fails to recognise the realities of nicotine addiction and the challenges faced by smokers attempting to quit. A harm reduction approach, on the other hand, acknowledges that while quitting smoking is the ideal outcome, it is not the only way to reduce harm. As such, harm reduction in the context of tobacco control entails providing smokers with less harmful alternatives, such as e-cigarettes, nicotine replacement therapies etc, to significantly lower the health burden associated with smoking. Overall, embracing harm reduction is not about endorsing nicotine use, but rather, it is about reducing diseases associated with tobacco smoking, thereby improving public health outcomes, and saving lives. It is time for South Africa to lead the way in tobacco harm reduction, just as it has in other critical areas of public health. By looking at examples from countries such as the UK, Sweden, NZ and leveraging its own public health expertise, South Africa can develop a more effective, compassionate, and pragmatic tobacco control strategy.