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A Decade of Tobacco Control: the South African Case of Politics, Health Policy, Health Promotion and Behaviour Change

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A Decade of Tobacco Control: the South African Case of Politics, Health Policy, Health Promotion and Behaviour Change RESEARCH A decade of tobacco control: The South African case of politics, health policy, health promotion and behaviour change P Reddy,1 PhD; S James,2 PhD; R Sewpaul,1 MSc; D Yach,3 MB ChB, MPH; K Resnicow,4 PhD; S Sifunda,5 PhD; Z Mthembu,6 MSc (Nursing); A Mbewu,7 MD 1 Population Health, Health Systems and Innovation, Human Sciences Research Council, Cape Town, South Africa 2 Health Promotion Research and Development Unit, Medical Research Council, Cape Town, South Africa 3 Vitality Institute, The Vitality Group Inc., New York, USA 4 School of Public Health, Department of Health Behaviour and Health Education, University of Michigan, Ann Arbor, USA 5 HIV/AIDS, STIs and TB (HAST), Human Sciences Research Council, Pretoria, South Africa 6 Natal Women’s Resource Centre, Durban, South Africa 7 Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa Corresponding author: P Reddy ([email protected]) Background. The South African (SA) government has implemented comprehensive tobacco control measures in line with the requirements of the Framework Convention on Tobacco Control. The effect of these measures on smoking prevalence and smoking-related attitudes, particularly among young people, is largely unknown. Objective. To describe the impact of a comprehensive health promotion approach to tobacco control amongst SA school learners. Methods. Four successive cross-sectional Global Youth Tobacco Surveys (GYTSs) were conducted in 1999, 2002, 2008 and 2011 among nationally representative samples of SA grades 8 - 10 school learners. We assessed the prevalence of current smoking (having smoked a cigarette on ≥1 day in the 30 days preceding the survey) and smoking-related attitudes and behaviours. Results. Over the 12-year survey period current smoking among learners declined from 23.0% (1999) to 16.9% (2011) – a 26.5% reduction. Reductions in smoking prevalence were less pronounced amongst girls and amongst black learners. We observed an increase in smoking prevalence amongst learners between 2008 and 2011. Smoking-related attitudes and behaviours showed favourable changes over the survey period. Conclusion. These surveys demonstrate that the comprehensive and inter-sectorial tobacco control health promotion strategies implemented in SA have led to a gradual reduction in cigarette use amongst school learners. Of concern, however, are the smaller reductions in smoking prevalence amongst girls and black learners and an increase in smoking prevalence from 2008 to 2011. Additional efforts, especially for girls, are needed to ensure continued reduction in smoking prevalence amongst SA youth. S Afr Med J 2013;103(11):835-840. DOI:10.7196/SAMJ.6910 Globally, tobacco use is the leading cause of consumption throughout the 1980s. After increasing by 140% premature mortality. The major health impact of between 1970 and its peak in 1991, aggregate cigarette consumption tobacco use in the future will be felt in low- and decreased by 39% between 1991 and 2004 (Fig. 1). middle-income countries[1] such as South Africa (SA). Since the late 1980s, SA researchers provided 100 B epidemiological and economic evidence that underpinned the need { for tobacco control legislation.[2] Beginning in 1994, with the election 90 A { of the first democratic government, a comprehensive set of measures 80 to mitigate the impact of tobacco use on human health were C 70 enacted. This included interventions at the ecological level, such as legislation banning the advertising of tobacco products, classifying 60 nicotine as an addictive drug, restricting smoking in public places 50 D and increasing excise duties on cigarettes. In addition, there were E F Packs/adult/year interventions aimed at individuals encompassing school health 40 education (e.g. changes in the national school curriculum declaring 30 nicotine a drug of addiction) aimed at improving health literacy.[3-6] 1960 1970 1980 1990 2000 2010 The Global Youth Tobacco Surveys (GYTSs) conducted in SA in Year 1999, 2002, 2008, and 2011[7,8] show the impact of tobacco control policies on youth smoking over a 12-year period. Fig. 1. National cigarette consumption from 1960 - 2009. Key events are Data for the same period based on market surveys, such as the indicated as follows: A: local government banned smoking in cinemas, All Media and Products Survey[9,10] showed sustained reductions in B: restriction on smoking on domestic flights, C: Tobacco Products Control SA cigarette consumption amongst adults. Per capita consumption Act of 1993, D: Tobacco Products Control Amendment Act no. 12 of 1999, decreased by 54% from 1999 to 2011. This sharp fall in per capita E: Tobacco Products Control Amendment Act no. 23 of 2007, F: Tobacco cigarette consumption followed a modest decrease in cigarette Products Control Amendment Act no. 63 of 2008. 835 November 2013, Vol. 103, No. 11 SAMJ RESEARCH Methods Data capturing and analysis The GYTS is a nationally and provincially representative cross- We sent the learners’ answer sheets to the CDC for electronic data sectional school-based survey conducted among secondary school capturing and preliminary analysis. On return to SA, the dataset learners.[11] We analysed data from independent GYTSs conducted in was further analysed using SAS software (version 9.2). In calculating 1999, 2002, 2008, and 2011. The sampling strategies, survey questions prevalence rates, the probabilities of sample selection (at the school and study procedures used were consistent across all the surveys. and class level) and non-response (school, class and student levels) were adjusted for using weighted data, which were post-stratified Sampling to approximate province level distributions of grade and gender. We In each year, a two-stage cluster sample design stratified by recoded the data from question responses into meaningful prevalence the country’s 9 provinces was used to provide nationally and variables and computed prevalence rates and 95% confidence intervals provincially representative data. At the first stage of sampling, (CIs). The prevalence of current smoking was examined for each of schools were the primary sampling units and were selected with the 4 survey years according to the demographic characteristics of a probability proportional to the school learner enrolment size gender, age, race, and grade. in grades 8 - 11. The national schools databases of all public Differences between individual prevalence estimates were schools containing grades 8 - 11 were obtained from the National considered statistically significant if p<0.05 and the 95% CIs did Department of Education (DoE), and provided the sampling frames not overlap. We merged the 4 datasets to examine the change in the for the first stage of sampling. We excluded private schools (4.4% of prevalence of current smoking over the 4 survey years. Controlling all schools) for logistical reasons. A total of 10 963 public schools for gender, age and race where applicable, we applied logistic with a combined grades 8 - 11 learner enrolment of 3.7 million were regression to the merged data to determine the effect of survey year eligible for selection.[12] on the outcomes of current smoking, with p<0.05 being considered At the second stage of sampling, grades 8 - 11 classes were selected significant. from each participating school, using systematic equal probability In addition, we analysed the prevalence of selected knowledge, sampling with a random start. All learners in the selected classes were attitudes and social influence items regarding tobacco smoke across eligible to participate. For each survey year, 23 schools per province the 4 survey years using logistic regression analyses to test the effect and an average of 2 classes per school were selected. of survey year on each outcome variable. We determined which smoking-related variables to investigate by testing their associations Questionnaire development and measurements with current smoking using logistic regression analysis. We adapted the standardised GYTS questions provided by the Centres for Disease Control and Prevention (CDC), USA[13] for Results relevance to the SA context. The questionnaire was developed Demographic characteristics in English and then translated and back-translated into the 10 In 1999, 6 045 learners participated in the GYTS; while the 2002, remaining official SA languages by academics proficient in the 2008, and 2011 surveys each captured over 8 000 learners (Table 1). respective languages. The final questionnaire included close-ended In each year, a marginally higher proportion of females than males questions related to (i) the socio-demographic characteristics of participated in the survey. Approximately half of the learners were the learners, (ii) tobacco use behaviour, (iii) access to tobacco ≥16 years, while between 44.7% and 45.7% were aged 13 - 15 years. products, (iv) knowledge and attitudes toward tobacco, (v) exposure The majority of the learners were black, with an increase from 54.1% to environmental tobacco smoke, (vi) attitudes regarding cessation, (1999) to 76.2% (2011). (vii) knowledge of media messages about tobacco, (viii) exposure to tobacco prevention education at school and (ix) community activities Prevalence of current smoking discouraging smoking. Nationally, the prevalence of current smoking among grades 8 - 10 Race was reported with the historical apartheid classifications: learners declined from 23.0% (1999) to 16.9% (2011) (Table 2, Figs black, coloured, Indian, white, or other. Learners were permitted to 2 and 3). This was statistically significant when controlling for race, answer that they did not know their race group. age, and gender in the regression model. Learners were considered to be current cigarette smokers if they Male learners had significantly higher current smoking rates responded positively to having smoked cigarettes on ≥1 day in the 30 than female learners, being almost twice that of females. Decreases days preceding the survey. in current smoking across the surveys were observed among male and female learners. A smoking increase was noted among female Ethics approval learners between 2008 and 2011, but was not statistically significant.
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