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Despite mastering harm reduction principles in its historic fight against HIV/AIDS, the South African government willfully ignores tobacco harm reduction as a potent tool in the battle to end smoking-related disease and death.

DR. PHINDILE SHANGASE - Senior Lecturer, University of Free State K•A•C Global Tobacco Harm Reduction Scholar
KURT YEO - Co-founder VSML Tobacco Harm Reduction Advocate @kurt_yeo


BRENT: And hi everybody, I’m Brent Stafford and welcome to another segment of RegWatch on South Africa, the southernmost country on the African continent is renowned for its great natural beauty, and cultural diversity. It also has the most industrialized and technologically advanced economy in Africa overall. Yet, there is one key advancement that is struggling to take hold, tobacco harm reduction. Joining us today to talk THR in Africa is Dr Phindile Shangase, Senior Lecturer at University of Free State and Kurt Yeo, Co-founder of Vaping Saved My Life. Thanks to you both for coming on the show. Dr Shangase, let’s start with you. You have a PhD in Public Health, focusing on smoking cessation. Please tell our viewers about what brought you to this topic and how it impacted your academic work.

PHINDILE: Thank you for inviting us.

KURT: Thank you Brent.

BRENT: Dr Shagase, let's start with you. You have a PhD in public health focusing on smoking cessation. Please tell our viewers about what brought you to this topic and how it impacted your academic work.

PHINDILE: Thank you. Actually, I was a board member. It's a drug resistance to be in the hospital. And I observed patients smoking within the hospital premises. And then I decided to research on these. Just [00:01:30] to find out what the barriers are to smoking cessation, because I know that no one will deliberately endanger their own health, especially when you've been diagnosed with drug resistant TB. So in my study, I interviewed both patients and staff. That was phase one study, and phase two was a survey that I carried out in three drug resistance, TB hospitals. And patients are also, you know, reporting that they really feel like quitting, you know, once they're diagnosed with drug resistance. But they did not get any practical help except for health education sessions that they were holding now in the hospital with the nursing staff. However, they could not get any practicality with regard to smoking cessation. And so I've had interest in the subject of smoking cessation ever since.

BRENT: I would imagine, Doctor, that if you have a if you have a TB patient, if you have TB and you're smoking, that must say something about the level of addiction and inability [00:03:00] to quit.

PHINDILE: Absolutely. Absolutely it does. And I'm not surprised that when I actually interviewed the patients, they mentioned those barriers ranging from personal factors to structural factors and other personal factors. They mentioned addiction related variables that pertain to smoking history. For instance, a number of them started smoking as teenagers and also a craving to smoke smoking as part of their daily routine. Most of them mentioned that within 5 minutes of waking up, you know, they had to have a smoke. And others have tried to quit but failed in those attempts due to lack of practical assistance.

BRENT: And Kurt, you've got some sad experience with quitting smoking. Tell us about Vaping Saved My Life. It's a consumer advocacy group. We know that that you co-founded. How did you come about creating it?

KURT: Thanks, Banks, and thank you for inviting us. You know, Vaping saved my life was basically started by myself and a good friend of mine who is a vape shop owner, Craig Stewart. Both of our struggles with smoking and smoking addiction. Both of us had been long term smokers. Me personally was 22 years as a smoker, 20 plus years. And at the peak of my smoking habit was more than 40 cigarettes a day. And I really did struggle. And even at the passing of my father, which was sadly the day before my planned wedding, even that wasn't sufficient enough for me to quit. And then like, like Craig and myself and so many other vapers in South Africa, we stumbled across this technology or this technology, and within a few days had managed to quit completely. But the smoking story didn't stop there. Some years later, I lost my mom to smoking as well, and she suffered from a stroke. And it was that that realization that there are so many of us that are struggling to quit smoking and watching our parents pass away and then coming to the realization that my own son would experience what I had just experienced, that this could definitely change a lot of people's lives. And we then decided to start a testimonial page on Facebook called Vaping Saved My Life back in June 2017. And since then we've gone from strength to strength, trying to share the message out there that this is definitely an alternative to people that have really tried to quit smoking but have failed. And for those people like myself that do rely on nicotine, that it is a safer alternative and it's something that should be looked at in in the entire South African context from a smoking cessation point of view.

BRENT: Is there something, Kurt, that you believe could make the situation in South Africa different than, say, in Canada or the US when it comes to the trials and tribulations of smoking and to quit smoking?

KURT: Absolutely. I think one of the biggest issues that we are confronted with is an illicit trade in really severe problem in illicit trade. There are some numbers from depending on the source anyway, between 50 to 70% of all cigarettes consumed in South Africa is from an illicit source. These products are really cheap and really accessible from anywhere and therefore circumnavigate anything like excise and any other restrictions that are currently in our tobacco bowl. So that's a significant problem. The other problem is just we don't have. Any cessation program to speak of in South Africa. We haven't implemented anything around Article 14 apart from the approval of Nazis and pharmaceutical drugs. But we do not have cessation clinics in South Africa. We don't have any social or counselling services at our primary and secondary health care services. So there's no assistance for smokers in South Africa to help them quit. And I think Dr Sugar's touched on that, is that these individuals are left on their own devices with a very cheap source of tobacco, and they forget that.

BRENT: And Dr Shangase, do you agree with that, that there certainly are some challenges in in South Africa that are unique to the situation?

PHINDILE: Yeah, absolutely. The smoking cessation programs, as Curtis just mentioned, I am not aware of any. Even while I was undertaking this study, although I'm aware that there've been some trials by some researchers, you know, to use some other means of trying to determine if the population that was being studied was able to quit over a certain period of time. However, with regard to standing interventions or cessation clinics, there aren't any that I'm aware of. And it was surprising that while I was researching literature and some of the policies and recommendations when I was undertaking my studies, I discovered that in South Africa there were already published guidelines by the Department of Health on the management of people with TB in special circumstances. They were published in 2014. And they recommended inclusion of behavioural and pharmacological treatment interventions for smokers. But those interventions were not available at the time. And also, the pharmacies confirmed that they they're not even in the essential medicine list at that time.

BRENT: So that's amazing to hear that there is not a real formal smoking cessation program that's sponsored by the government or even like, you know, non-profit public health groups. Let's just take a quick look here and thanks for shooting this information over Curt. This is the global adult tobacco survey for South Africa from just last year. And it's not easy to get real up to date statistics. And it's quite amazing. Nearly 30% overall, 12.7 million adults use tobacco. 41% men and basically 18% of women. We're talking about a lot of tobacco use.

KURT: Unfortunately, we do not have a lot of research and study in this field and we do not monitor these the smoking and smoking prevalence in South Africa consistently and continuously. This is, you know, this global adult tobacco survey was the first one ever conducted in South Africa. And that's rather alarming, given the fact that we had ratified with the CTC in 2005. And just to go back to what Dr Sugar also says, there is only one sensation clinic in the entire republic and that is found in Cape Town at the Hospital of Grotowski. And there is no other clinic anywhere else. We don't have a toll free helpline or quit line and we don't offer in our teas subsidised through public health at all. So this is a rather pervasive issue, an alarming issue around public health in South Africa. If this is a problem at a third, almost a third of our population is smoking and there is no assistance whatsoever.

BRENT: How popular is e-cigarettes in South Africa?

KURT: Well, according to the that particular study you showed there, the global adult tobacco survey of South Africa, only 2.2% of current users and 6.2 had ever tried. The issue around South Africa is that we have probably the most unequal society in the world, is that we have an enormous lower class unemployed population and a very small middle class and upper class who are the only people that can afford this kind of intervention, which is deeply alarming and sad because, as Dr Sarkozy has pointed out, the majority of our smokers are falling into lower middle and lower income groups or generally unemployed and or stuck with addictions, not only in smoking, but around alcoholism as well as drug abuse. So there is a massive issue around us and it needs an urgent it needs urgent focus on.

BRENT: Dr Shangase. I mean, what are your thoughts on H.R.? Clearly, if there's not even regular smoking cessation, there can't be a lot of adoption of HR policies then in South Africa.

PHINDILE: And I would say that they do consider the issue of smoking cessation seriously. I have also seen in some of the recommendations on the treatment of conditions, you know, that that speak to smoking, that patients need to be encouraged to quit smoking. And there's been an ongoing debate. However, I think the lack of, you know, clinical evidence on some interventions, like, for instance, tobacco harm reduction, it leads to policies or action not being implemented immediately. So I feel that as researchers, we still need to undertake more studies, you know, just to show how much harm could be reduced by particular products that can be used by those who smoke, because it's a matter of public health to reduce the harm on the health of the population.

BRENT: Excellent. Thank you. Kurt, let me ask you this. Is there a war on Vaping in South Africa?

KURT: Um. Absolutely. The government wants to treat vaping and vapers as the same as smoking and combustible tobacco and vape. So there is no clear distinction. There's also an overreliance on what has been provided by the World Health Organisation to South Africa and they in my view, turn a blind eye to some of the experiences that we're seeing in the UK and in other parts of the world. There is very little research around cessation in using tobacco harm reduction products in South Africa. There is a handful of studies, but unfortunately those studies are not really, in my opinion, worth, worth it. And it is rather sad because South Africa is not a stranger to harm reduction. In the nineties we had an enormous problem around HIV and AIDS, and at that stage we had a lot of misinformation around HIV and AIDS. Such to the extent that our highest leaders, president, as well as the Health Department, denounced the fact that that HIV caused AIDS, and they were promoting things like beetroot and homeopathic remedies to help these patients. It was only when civil society and social groups stood up and started combating this particular narrative that the then president did an about turn. We now do have the largest HIV AIDS response in the world. We don't only do antiretrovirals, but we also provide free condoms to people in the public health service and people that are using the public health service. We also provide free circumcision, all in the name to reduce the spread of HIV in the country. So Harm Reduction is no stranger, and I think that the government should be looking to its two commercial partners to see how we can not only bring Vaping into the country at a much lower price point, but look at other products like nicotine patches or heat, not burn products and make sure that we're looking at. Meeting the smoker where they are at. Rather than just hitting them with a blunt object around stigmatization, high, high taxes and severe restrictions. So it's not impossible. These products are nowhere near the price point that we that we used to see with HIV and AIDS medication. It is doable.

BRENT: South Africa has a new tobacco and vape bill heading to parliament. There's also an excise tax on vaping products that's going to go into effect in January of 2023. What are these initiatives going to do to the vaping market? The availability of vapes have for the affordability of vaping in South Africa.

KURT: Brent. I think it's going to have a very negative effect on the on the industry as well as the Vipers itself. My biggest fear is that this will now go completely underground and we'll lose complete control over the situation. So the real start looking at reduced quality and standard of these products because we will start seeing home brews and DIY and products being imported from anywhere parts of the world. And just purely because we now understand that the illicit market is so strong within South Africa, around cigarettes is nothing stopping them, including vaping products in the same in the in the same category or the same category. And then we have something like an adulterated product like we saw, although not it wasn't nicotine, but the evolving situation in North America where there was tainted products. This could be a real risk to South Africa if we lose control around these products. And I believe that increasing this tax on a volume base which will see more than 116% increase on these on e-liquids will force us underground and we've lost control.

BRENT: Doctors Shangase.

PHINDILE: Yeah. I would just say that, yes, there is a high possibility of illicit cigarettes taking over, you know, choose to hide something. And during my study, some patients mentioned that they have a cheaper cigarette they get from somewhere that after smoking, you know, they cough a lot. And this causes a lot of changes on the road, but it's the cheapest that they could get. And from the studies that I have reviewed, quite a number of those that cannot afford expensive cigarettes, they end up rolling their own. And in so doing, they add substances that may not be acceptable to have. That's one. That's one word of it. On the other hand, I feel that the more sage discussion with regard to how Vaping assist in Harm Reduction to show more everything, the better it is. If you look at Harm Reduction initiative with regard to HIV, even nowadays, there are still a number of clinical trials that take place, and such results convince policymakers that this actually works. You know, and this is how it can be done and so on and so forth. And also there are follow ups on participants. So I feel that if maybe the same approach could be helpful just to show everything to policymakers that actually the use of nicotine via vaping is completely different, you know, from essentially lighting up the cigarette. And this is the evidence that actually reduce harm because I think that's what they mostly need to show. And there are so many debates out there when it comes to smoking cessation, you know, what works, what doesn't work, and so on and so forth. But the availability of evidence, I feel that we make more difference and a better influence and more understanding because that's where we're lacking as well. You know, more understanding on how vaping works in relation to cigarettes, but evidence is needed as well. Thank you.

BRENT: Dr Shangase, how familiar are you with the Global Forum on Nicotine? GFN which was just the big event in Warsaw last June, is that a conference that you think is important and why?

PHINDILE: Oh yeah. Really impressed you when attending that conference. There is so much information on how nicotine works, you know, and so on and so forth. There were a number of researchers, policy makers and so on and those from the tobacco industry trying to outline how they tried to reduce the harm. And there are quite a number of debates as well. And the activists like KURTZ, whom I felt are also important role players because, you know, they are the users. They can tell us how much difference is making on their own, their lives. So yeah, the conference was quite big and important in knowledge sharing.

KURT: I think it's absolutely critical. It's incredibly valuable to individuals like myself around the world who are fighting this fight on the front line and feel it's it's a personal affront on us to to have these products just pushed aside based without not taking our point into consideration, our life experiences into consideration. And that's why we are and I say we, but I'm sure I can speak on behalf of many consumer activists there that we are rejected from attending or at least sharing our experiences and our thoughts at things like COP nine, where we feel that that is critical in the discussion and in formulating policies to ultimately get to where everybody wants to get to. And that is reduce the harm and death related to combustible tobacco.