However, a meeting on Wednesday, provided South Africans a long-overdue platform to propose alternate positions on what is, globally, an advanced conversation.
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. Van Zyl-Smit, on the other hand, believed that there is not 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.
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.
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%.”
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.
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”.
He 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.
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.
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.”
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. “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,” he said.
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.
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.
