Lessons from tobacco control in South Africa

By Aram Barra

Throughout human history, all societies that have had access to a psychoactive substance have in fact used it and have found a way to regulate it. This is, whether for medical, recreational or traditional purposes –to name a few of the reasons behind drug use– societies have always controlled use by limiting it to particular festivities or certain groups such as elites, shamans, etc. This remains true for tobacco, which was first used in the Americas for curative and spiritual purposes but was soon enough –with a little help of colonisation first, and globalisation after– popularised and commercialised around the world.

Rembrandt Tobacco Manufacturing Company

Rembrandt Tobacco Manufacturing Company in South Africa.

Throughout the 90s, South Africa became one of the highest rates of tobacco smoking in the developing world. By 1999, chronic diseases of lifestyle such as ischemic heart disease, stroke, diabetes, and smoking-related diseases, accounted for 24.5% of reported deaths (Medical Research Council 2006). This reality made tobacco control a high priority in the public agenda of the first post apartheid government led by Nelson Mandela, although he had publicly supported tobacco control since as early as 1992.

Under the leadership of the country’s Minister of Health, Dr. Nkosanza Zuma, and following on pioneering control efforts in Canada, Finland, Norway, Singapore and the US, South Africa established five legislative goals around tobacco regulation: 1) to establish government policy around tobacco control; 2) to encourage cessation and reduce smoking initiation; 3) to protect the rights of non-smokers; 4) to reduce harmful substances in cigarettes, and 5) to allocate funding for tobacco control programming (WHO 1999).

The political discussion and policy building process in South Africa provided fertile ground for the systematization of good practices and overall learning around tobacco effective regulation. With a mix of policy tools including tax increases, bans on advertisement, indoor air laws, public education and expansion of the access to forms of treatment, smoking prevalence declined from 33% in 1993 to 30% in 1996 and 23% in 1999. Continuation of these policies has today successfully lowered the country’s smoking prevalence to 16.9% (2011).

South Africa’s tobacco regulation demonstrates that sustained tax increases are a very effective and inexpensive policy tool, although as some countries are today learning, there is a limit to how much you can raise the price without over-fostering a black market. To find the right level of taxes, the Economics of tobacco Control Project in South Africa estimated price elasticity of demand of -0.59 in the short run and -0.69 in the long run. (Benowitz, 2008).

Moreover, complete advertising bans reduce consumption and, when complemented with education campaigns, decrease in the prevalence of use is much more succesful. In South Africa, the World Bank calculated and average prevalence reduction in between 7% to 9% when bans are fully implemented. Product information and health warning educated consumers about the hazards of smoking and tar and nicotine content labelling on cigarette packages provides smokers with knowledge about cigarette content as well.

Lastly, clean indoor air laws protect non-smokers from exposure to second-hand smoke and encourages smokers to quit. For this, nicotine replacement therapies and pharmacological products that aid cessation must be accessible. As learned by South Africa, a combination of these strategies doubles the success rate of other counselling-based interventions and reduces smoking rates.

All psychoactive substances implicitly convey a level of risk both to the individual that uses them and the overall health of our communities. The lessons learned from tobacco in South Africa are not ones to remain in history books, but must be studied and adapted to fit various contexts around the world. What is more, while there is no ‘one size fits all’ in public policy, a combination of the available policy tools may result in higher impacts with more effective results.

After all, it is up to us to make sure new generations stay healthy, but that if in their exercise of personal freedom, individuals decide to use tobacco, they have all the information and education they need to make sure their actions are as least harmful as possible.

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