Tobacco Products Control Amendment Bill 2008

1. Tobacco Products Control Amendment Bill 2008 MRC Submission to the Parliamentary Portfolio Committee on Health May 2008

2. Tobacco Products Control Amendment Bill 2008 Prof AD MBewu BA (Oxon) MBBS (London) FRCP (UK) MD (London) PMD (Harvard) FMASSAf President, South African Medical Research Council Specialist Cardiologist and Visiting Professor in the Department of Medicine, Faculty of Health Sciences, University of Cape Town Co-Chair Inter-Academy Medical Panel The Medical Research Council supports the Tobacco Products Control Amendment Bill 2008 • South Africa, as a signatory, is obliged to comply with the stipulations of the Framework Convention on Tobacco Control (FCTC) – WHO’s first global public health treaty • Evidence that public health benefits from a rigorously enforced ban on smoking in public places and on smokeless tobacco is indisputable; particularly for young people. • Legal implications of not enforcing such a ban, in terms of litigation from those harmed by second-hand smoke, is likely to become apparent in years to come, due to recent research evidence on the health effects of second-hand smoke.

3. Tobacco Control Legislation - benefits • The MRC is proud of the fact that its research played a part in the formulation of South African Government legislation on tobacco control since 1993– as part of fulfilling our vision of ‘Building a healthy nation through research’. • South Africa is at the forefront of Tobacco Control worldwide in terms of legislative interventions as well as public health research. • Legislative levers have become the most powerful health promoting mechanisms to reduce smoking within entire populations. • Successive hikes in excise duties on cigarettes since 1992 have aided in reducing tobacco consumption through a mechanism known as ‘the price elasticity of demand’ whereby a 10% increase in the real price of cigarettes results in a 6% reduction in aggregate consumption. • The lost revenue as a result of this reduced consumption is more than offset by the increase in excise duty income (Economics of Tobacco Control, UCT) • This is particularly effective amongst those on low income budgets – who are also the ones disproportionately affected by the health effects of tobacco. • As the seminal MRC Report in 1998 showed : the costs of smoking far outweigh the benefits • The Tobacco Control Amendment Act of 1999 had the important effect of protecting the South African public from the harmful effects of tobacco. • From 1990 to 2004 tobacco consumption in South Africa declined from 2-billion cigarettes p.a. to 1.3-billion – at a time when tobacco consumption was expected to rise due to the rapidly increasing disposable income of the majority of the black population of South Africa.

4. Tobacco Control Legislation – continued • In 1992 32% of the adult population of South Africa were smokers – by 2003 this had fallen to 24% • Tobacco is estimated to reduce the lifespan of 50% of those who smoke by at least 10 years. The fall in prevalence of smoking from 1992 to 2003 would imply that 8% (1.9 million) of the adult population have been spared the pernicious effects of smoking which would have reduced the lifespan of 960 000 of them by 10 years. • The economic benefit from such a change is enormous in terms of disability adjusted life years saved. • South African tobacco control legislation is a tremendous achievement in public health, as it translates into dramatically-reduced death and disability from heart disease, strokes, cancers and chronic lung disease – all of which are commonly caused by tobacco. • In 2000 according to the South African Demographic Health Survey 43.7% of South African men were smokers; compared with 11.1% of women • In addition, South Africa has played a significant role in developing the Framework Convention on Tobacco Control (FCTC) which was adopted at The 54th World Health Assembly in May 2003 in Geneva, Switzerland. • South Africa was one of the earliest signatories of the FCTC; and is therefore compelled to ensure that its tobacco legislation adheres to certain regulatory standards. • The Tobacco Control Amendment Bill 2008 would ensure that South Africa complies with its FCTC obligations. • Other developing countries across the world look at South Africa as a leading example in tobacco control. • The Disease Control Priorities Project of the World Bank and WHO estimates that tobacco control programmes (TCPs) are highly cost-effective in preventing death and disability, costing US$57-US$70 per disability adjusted life year (DALY)saved.

5. Global Smoking Statistics • An estimated one third of the adult male global population smokes. • Every year, smoking-related diseases are responsible for one in 10 deaths globally. If current trends continue, this will rise to one in six by 2030 • The 5-million tobacco deaths annually, compared with 2.5 million deaths from HIV/AIDS, makes smoking the number one preventable cause of death and disability in the world. • Even though smoking incidence is on the rise in the developing world, it is decreasing in developed nations. Among Americans, smoking rates fell by almost half in three decades to 23% of adults by 1997. Tobacco consumption in the developing world is rising by 3.4% per annum. • The expected continuing decrease in male smoking prevalence will be offset by an increase in female smoking rates, especially in developing countries. • A recent study of second hand tobacco smoke in non-smoking women and children in 31 countries demonstrated secondhand tobacco smoke (air nicotine) in the houses of 80% of these women and children, as well as outside their homes; and also nicotine deposits in their hair

6. Smokers in South Africa (%) – South African Demographic Health Survey 1998

7. Global Smoking Statistics– continued • An estimated 1.3-billion people smoke and 84% of all smokers live in developing and transitional economy countries. Half of all smokers – about 650-million people – will eventually be killed by tobacco. • A startling 15 billion cigarettes are sold daily – 10 million every minute. • Among teenagers aged 13 to 15, about one in every five of them smoke worldwide. • Between 80 000 and 100 000 children start smoking every day across the world. • Evidence shows that around 50% of those who start smoking in adolescent years continue to smoke for 15-20 years. • The South African Comparative Risk Assessment 2000 Study, from the MRC’s Burden of Disease Research Unit, ranked tobacco 4th on the list of leading causes of death and disability, accounting for 4% of DALYs lost. • The MRC National Burden of Disease Study 2000 revealed that tobacco was responsible for 8.5% of deaths, the third commonest cause of death after HIV and AIDS, and high blood pressure. This equates to 41 632 – 46 656 deaths out of the 521 000 deaths from natural causes in that year • Tobacco is deadly in any form of disguise – cigarettes, pipes, biddies, kreteks, clove cigarettes, snus, snuff, smokeless, cigars, mild, light, low-tar, fruit-flavoured, chocolate-flavoured, natural, additive-free.

8. Smoking Inequities • Evidence is growing about the influence of sex, gender and diversity on tobacco use in several developed countries. • Epidemiological data shows that smoking follows a class gradient of health in the USA and most developed countries. • In Canada, for example, at the lowest income level, smoking prevalence among women was about 35% and 41% among men between 1996-1997. In contrast, smoking prevalence at the highest income level was 18% for women and 22% for men. In the USA, the socioeconomic status and level of education have become strong predictors of tobacco use. • In countries like India, China and Thailand there is a marked gender difference, with significantly more males than females smoking. • Both biological and social factors impact on vulnerability. For example, children of women who smoke while pregnant are more likely to become smokers because of biological predispositions established during foetal development. • Additionally, children whose mothers smoke are most likely to smoke as a result of role modelling.

9. Tobacco Use and Poverty The WHO’s stance is well known on tobacco use and poverty as reflected by the following statements: • Tobacco and poverty are inextricably linked. Many studies have shown that in the poorest of households in some low-income countries as much as 10% of a total household expenditure is spent on tobacco. • This impacts on health and education, resulting in deprivation – which leads to malnutrition, increased health care costs and premature deaths as well as higher illiteracy rates. • Smoking also contributes to hunger across the world, as the tobacco industry diverts huge amounts of land (from producing food) to producing tobacco. • This devastates economic costs associated with high public health costs for treating diseases caused by tobacco; it deprives families of breadwinners through premature deaths from tobacco-related diseases; and deprives nations of their healthy workforce as tobacco users are less productive while alive due to increased sickness.

10. Impact of Environmental Tobacco Smoke (ETS) • A survey of 1284 households in 31 countries revealed air nicotine and nicotine in the hair of those exposed to second hand smoke in the home and in public places (Wipfli H, Journal of Public Health 2008) • The impact of ETS on coronary heart disease has only been studied intensively over the past 20 years. • These studies were made possible by the introduction of laws which restricted smoking inside the workplace and all public buildings – including restaurants, bars, bowling alleys and other business establishments. • Comparative studies were carried out at two levels: before and after the introduction of the law within an area and between areas where the law was imposed, with one where the law was not imposed. • The findings showed a 30% decrease in hospitalisations for heart attacks during a city-wide smoking ordinance in Pueblo, Colorado, USA. There was no decline in the neighbouring El Paso County, where a smoking ordinance was not introduced.

11. Impact of Environmental Tobacco Smoke – continued • During the six month period of a ban on smoking in public places in Helena, Montana, there was a 60% reduction in the number of heart attacks in the communities surrounding Helena using the same regional hospital. • However, the reduction was not evident in the area not affected by the smoking ban. Unfortunately, after the ban was lifted, admission rates for heart attacks rose again. • It is estimated that smoke-free workplaces would significantly reduce the number of strokes and AMIs in non-smoking individuals in the first year alone • In February 2008, Circulation, the world’s leading heart journal, reported that one of the effects of study on a smoking ban in Italy in 2005, was a reduction in heart attacks compared with the period 2000-2004. • The study, undertaken in Rome, revealed an 11.2% reduction in heart attacks in 35-64 year-olds, and a 7.9% reduction in 65-74 age group.

12. Mechanism by which Second-hand Smoke Causes Heart Attacks Exposure to second-hand smoke acts rapidly, within 30 minutes: • It makes the platelets in the bloodstream more sticky causing blood clots, which block the arteries supplying the heart, causing a heart attack. • During passive smoking, some of the endothelial cells which line the arteries and create raw surfaces, are killed. Platelets stick to these raw surfaces and cause blood clots. • It may be causing arteries to go into spasm and increase the likelihood of blood clot formation. • Nicotine and carbon monoxide in second-hand smoke cause heart rhythm disturbances.

13. Mechanism by which Second-hand Smoke Causes Heart Attacks • Nicotine and carbon monoxide can be measured in the body for 40 hours after a 30-minute exposure to second-hand smoke • Thirty minutes is less than the time it takes to enjoy a light meal • The effects on the platelets as well as the lining of the arteries (of a passive smoker) are as large as those of a packet-a-day smoker. • In people with spouses who smoke, the individual risk of a heart attack associated with passive smoking is about 30%. • The levels of second-hand smoke in workplaces, bars and restaurants have measured much higher than it would have in the homes of smokers.

14. Effects of Smokeless Tobacco • Smokeless tobacco is not harmless. While there is little evidence to link it with an increased risk of cardiovascular disease, some smokeless tobacco products in India and America have caused oral cancer. • Smokeless tobacco has other physical consequences, such as cancers of the oral cavity, pharynx, larynx and esophagus; damaged gum tissue; increased sensitivity to cold and heat; loosened teeth, which can eventually fall out; and a reduced sense of taste and an inability to smell. • Smokeless tobacco use is an effective delivery system for nicotine and is therefore addictive. However, it is considered to be less harmful and promoted as a reduced-harm product. In South Africa it is perceived to be less harmful and a safe alternative for cigarettes by two thirds of the youth.

15. Effects of Smokeless Tobacco- continued • A study by Ayo-Yusuf et al confirmed that the South African brand of snuff has a high nicotine content and therefore continues to pose an addictive risk to the user with subsequent health risks. • The risk to the user of a smokeless tobacco product varies by product and is to some extent uncertain – notably in the area of heart disease. • Most young people do not use smokeless tobacco. A recent Missouri study showed that 14% of high school seniors reported being current users of smokeless tobacco, of whom one-half were daily users. Of those students who have used smokeless tobacco, the majority first tried it in grade school; and smokeless tobacco is used more often in rural than in urban areas. • Smokeless tobacco products like snus can act as a ‘gateway’ drug for young people, due to the highly addictive nature of nicotine, subsequently ensuring that a young person becomes a consumer of cigarettes.

16. Tobacco Use and Gender • Until the 1980s tobacco use in women focused on reproductive health issues relating to pregnancies. More comprehensive consideration of issues connected to women’s health, socioeconomic conditions and tobacco use is a comparatively recent phenomenon. • Women are vulnerable in terms of exposure to passive smoking and its subsequent health effects; household poverty from compromised family nutrition – enforcing empowerment to protect their families from ETS and an advertising media which is increasingly targeting the working class as well as disadvantaged girls and women. • Evidence shows that over the past two decades, more teenage girls than boys are smoking in industrialised countries. • Over the past 25 years considerable evidence have accumulated on gender differences in the effects of tobacco on girls and women and gender influences on tobacco-related behaviours such as initiation, maintenance and cessation. • More recently gender was recognised as a key determinant of health and associated with elements of disadvantage or identity. Research to explore the psychosocial and economic underpinnings of smoking women in the 21st century was indicated.

17. The Global Youth Tobacco Survey • The Global Youth Tobacco Survey (GYTS) was a school-based survey of 13-15 year olds in 395 sites in 131 countries. • In adolescence the majority of customers are recruited to a lifetime of smoking through the addictive effects of nicotine. • Adolescents are vulnerable to ‘below-the-line’ advertising which encourages them to smoke. • Furthermore, adolescents that are exposed to environmental tobacco smoke from adults who smoke. • GYTS data from 1999-2005 suggest that the effects of tobacco use on worldwide deaths could be even greater than expected. • GYTS is important as the tobacco industry worldwide continues to (indirectly) target young people (addict them young and they become customers for life); and therefore trends around the world in smoking by youth needs to be closely monitored

18. The Global Youth Tobacco Survey (GYTS) • The MRC’s Health Promotion Research and Development Group, directed by Prof Priscilla Reddy, conducted both the South African GYTS in 1999 as well as 2002. • It provided South Africa with nationally representative data on youth tobacco consumption, recruiting 8 935 learners. • This placed the GYTS in a unique position to fortuitously evaluate the impact of tobacco legislation which was promulgated in 1999 and implemented in 2001. • GYTS statistically showed a significant drop in the learners who ever smoked from 47% to 38%. • There has also been a significant decrease in the number of frequent smokers. • South Africa, represented by the MRC, plans to participate in the next GYTS

19. National Youth Risk Behaviour Survey • The National Youth Risk Behaviour Survey (YRBS) 2002 conducted by the MRC revealed that 21% of learners were current smokers (29% males and 15% females). • The addictive nature of cigarettes amongst South African youth was evident with 47% of the learners who smoked reporting that they have tried unsuccessfully to stop smoking. • Of the current smokers, 84% reported being exposed to environmental tobacco smoke; as did 56% of the never smokers • The MRC Health Promotion Research and Development Unit in 2007 completed a randomised control trial of two different behavioural smoking interventions in smoking cessation amongst school learners – demonstrating that both were effective, but in different settings. • This work could be used in South African school curricula to assist learners who smoke to quit. • The MRC is currently repeating the YRBS in 2008

20. Risk Factors for Disease • The MRC Burden of Disease Research Unit Comparative Risk Assessment Study showed burden of disease from the top 10 risk factors for disease by DALYs • A disability adjusted life year (DALY) is a measure that combines mortality (years of life lost due to premature death) with morbidity (years of healthy life lost) in one indicator : • Unsafe sex/STDs 32% • Violence 9% • Alcohol 7% • Tobacco 4% • Obesity 3% • Being underweight 3% • Unsafe water 3% • Hypertension 2% • Diabetes 2% • High cholesterol 1%

21. Chronic Diseases • The use of tobacco has consistently become one of the main preventable causes of chronic diseases and premature mortality. • Smoking is the second leading cause of death globally, accounting for seven million of the 57-million deaths annually. • Moreover, a variety of different modelling approaches suggest consistent worldwide increases over the next 2 decades in mortality attributed to tobacco use. • The Government’s tobacco legislation is important for preventing the increase in heart disease and strokes • It is complemented by other initiatives, such as the Department of Health’s Youth Fitness Charter and VukaSouth Africa! • GYTS and the National Youth Risk Behaviour Survey of 2002 were useful in studying the risk factors that cause these diseases, and a YRBS should be repeated within the next 12 months.

22. Inequalities in Health • The greatest part of the ‘National Project’ for South Africa over the next 10 years is to reduce the gap between rich and poor – specifically by halving poverty by 2015. • The poor are disproportionately affected by tobacco as work by Prabhat Jha et al shows that smoking accounts for more than half of the difference in death rates between the richest and the poorest 25% of middle-aged men in some European countries and North America. • On average, across these 4 countries, the probabilities of being killed at age 35-69 by smoking were 5% for the highest versus 17% for the lowest social strata (absolute difference of 12%). • As we aim to decrease the gap between rich and poor, therefore, tobacco control should become a priority (Jha P, et al Lancet 2006; 368 : pp367-370)

23. Conclusions • South Africa was one of the earliest signatories of the FCTC; and is therefore compelled to ensure that its tobacco legislation is in line with FCTC stipulations. This amendment bill would ensure that it is done. • In addition, the many ‘loopholes’ that have emerged since the Act of 1999, which allow smoking products to be promoted to young people especially, need to be closed. • The penalties for infringing such legislation must be increased in order to further reduce the number of young people who become addicted to nicotine. • The exposure of members of the public to the harmful health effects of environmental tobacco smoke needs further reduction. • Tobacco products such as snus or other smokeless tobacco, are not harmless, and serve as ‘gateway drugs’, addicting the child to nicotine, so that they subsequently become cigarette consumers when old enough to do so • Tobacco legislation in South Africa is equally important on an international level, as many developing countries follow the lead of South Africa to promulgate their own legislation; and tobacco-related diseases are the fastest-growing cause of disease and disability in developing countries.

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