Tobacco control has achieved much in the past 50 years in many countries of the world, including South Africa where smoking amongst adults fell 54% (1) between 1994 and 2012 : from 34% to 17.6%; and amongst children fell 26.5 % between 1999 and 2011 (from 23.0% to 16.9%) (2). Much of this has been achieved through comprehensive tobacco control measures introduced by the South African Government including successive hikes in tobacco excise duties, and the prohibition of smoking in public places (2). South Africa was also one of the earliest signatories to the WHO Framework Convention on Tobacco Control which harmonises tobacco control efforts amongst 77 countries globally, most of them the low and middle income countries in which 80% of smokers reside (3).

However, tobacco remains the second leading cause of death in the world killing more than 7 million people a year through causing heart disease, lung cancer and chronic obstructive airways disease. More than 6 million of those deaths are the result of direct tobacco use while around 890 000 are the result of non-smokers being exposed to second-hand smoke (3).
Furthermore, despite declines in smoking in high income countries, tobacco use continues to increase in low and middle income countries, and amongst young women, and if trends continue will cause one billion deaths in the 21st century.

In addition to targeting low and middle income countries, the massive global tobacco industry has also shifted its strategy to promoting electronic cigarettes; with some companies claiming they intend to exit the combustible cigarette business in the future. Though e-cigarettes are said to be less harmful than cigarettes, they are not without risk to health; and the user continues to be addicted to nicotine, a very difficult habit to kick (4). Cigarette companies claim that e-cigarettes help cigarette smokers to quit, but there is no good evidence for this; and many smokers end up using both e-cigarettes and cigarettes in the false hope that they have thereby reduced their risk of lung cancer. If e-cigarettes were primarily for smoking cessation, they would be available only on prescription by doctors as part of a cessation programme. Lastly there is compelling evidence that e-cigarettes act as a “gateway drug” for young people to transition to cigarette smoking (4).

Also, the vapour produced by e-cigarettes, which contains nicotine and other chemicals, could potentially be harmful to non-smokers (4); which is why most countries, including South Africa, ban smoking cigarettes in public places and have initiatives toward banning e-cigarettes in public places.

This is important because public health research has shown  that smoking products in the air can precipitate heart attacks : when a ban on smoking in public places in Helena, a small town in Montana was reversed after 6 months, the rates of admissions for heart attacks rose by 40% (5).

Recent evidence has shown that while conventional cigarettes nearly treble the risk of a heart attack, e-cigarettes almost double the risk, and dual use of cigarettes and e-cigarettes increase the risk of a heart attack five-fold; suggesting that chemicals in the vapour of e-cigarettes may magnify the known risk of conventional cigarettes in causing heart attacks (6). This is important because many users of e-cigarettes are “dual users”, using both conventional cigarettes and e-cigarettes. It could also imply that “second hand vapour” from e-cigarettes might be harmful, and their use in public places should continue to be banned.

For all these reasons South Africans and people all across the world must continue in engaging in responsible public health actions in their efforts to further reduce the use of all tobacco products, including snuff and e-cigarettes, so as to reduce the millions of deaths and the untold misery and suffering that tobacco products cause. Importantly, the use of tobacco products, which are highly addictive, contribute to household poverty and rising medical care costs.

References
1.    Priscilla Reddy, Khangelani Zuma, Olive Shisana, Kim Jonas, Ronel Sewpaul. Adult Tobacco Use Prevalence in South Africa: Results from the First South African National Health and Nutrition Examination Survey.  South African Medical Journal 2015; 105 (8):648-655.
2.    P Reddy, PhD; S James, PhD; R Sewpaul, MSc; D Yach, MB ChB, MPH; K Resnicow, PhD; S Sifunda, PhD; Z Mthembu, MSc (Nursing); A Mbewu, MD. A decade of tobacco control: The South African case of politics, health policy, health promotion and behaviour change. South African Medical Journal, 2013; 103
3.    WHO report on the global tobacco epidemic, 2017: monitoring tobacco use and prevention policies. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO.
4.    Grana R, Benowitz N, Glantz SA. E-cigarettes: a scientific review. Circulation. 2014 May 13;129(19):1972-86. doi: 10.1161/CIRCULATIONAHA.114.007667.
5.    Sargent RP, Shepard RM, Glantz SA. Reduced incidence of admissions for myocardial infarction associated with public smoking ban: before and after study BMJ. 2004 Apr 24; 328(7446): 977–980.
6.    Alzahrani T, Pena I, Temesgen N, Glantz SA. Association between electronic cigarette use and Myocardial infarction: results from the 2014 and 2016 National health interview surveys. Abstract presented at the 2018 annual meeting of the Society for Research on Nicotine and Tobacco on February 24 in Baltimore.

For further information contact:

Professor Priscilla Reddy
Acting Executive Director
Population Health, Health Systems and Innovation (PHHSI)
Human Sciences Research Council
3rd Floor,Merchant House, 116 – 118 Buitengracht Street, Cape Town,8001
Tel:+27 21- 466 7870
preddy@hsrc.ac.za

Alternative contacts:
Ms Rachana Desai
rdesai@hsrc.ac.za
Ms Ronel Sewpaul
rsewpaul@hsrc.ac.za