intersectoral case study Successful Tobacco legiSlaTion in SouTh africa South Africa conTenTS Prof. Karen J. Hofman, MBBCh, FAAP Summary ..................................................... 2 Director Introduction ................................................... 2 Priority Cost Effective Lessons for Systems .................................................. Strengthening Methodology 2 MRC, University of Witwatersrand 1. General background ......................................... 3 Faculty of Health Sciences School of Public 1.1 Trends in smoking prevalence ............................ 3 Health Johannesburg, South Africa 1.2 The health burden of tobacco ............................. 3 1.3 Brief history of South African ties to tobacco ............... 4 Richard Lee ........................................ Intern 2. Initiation of the policy 4 PRICELESS-SA (Priority Cost Effective 2.1 Early academic action ................................... 4 Lessons for Systems Strengthening – SA) 2.2 Early government action ................................. 5 Correspondence: 3. Description of the policy ..................................... 5 Prof Karen Hofman 3.1 The Tobacco Products Control Act, its regulations, Room 231, Wits School of Public Health ....................................... Education Campus, 27 St. Andrews Road, and amendments 5 Parktown 2193 Johannesburg, South Africa 3.2 Taxes on tobacco ....................................... 6 Landline: 011 717-2083 3.3 Further regulation considerations ......................... 7 Cell: 076 439-2486 Email: [email protected] 4. Process of intersectoral action ................................ 7 4.1 Passing the Tobacco Products Control Act of 1993 .......... 7 4.2 Strengthening tobacco regulations under a ISBN 978 92 9 023232 2 new government ........................................ 8 4.3 Economic responses from the tobacco industry ............ 8 © WHO Regional Office for Africa, 2013 ................... Publications of the World Health Organization enjoy 4.4 Responses from the hospitality industry 8 copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All 4.5 Monitoring smoking in South Africa ....................... 8 rights reserved. Copies of this publication may be obtained from the Library, WHO Regional Office for Africa, P.O. Box 5. Conclusions ................................................ 9 6, Brazzaville, Republic of Congo (Tel: +47 241 39100; Fax: +47 241 39507; E-mail: [email protected]). Requests ............. for permission to reproduce or translate this publication, 5.1 Progress made among the South African youth 9 whether for sale or for non-commercial distribution, should be sent to the same address. 5.2 Remaining challenges for South Africa ..................... 9 The designations employed and the presentation of the 5.3 Policy recommendations for other low-and-middle material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health ...................................... Organization concerning the legal status of any country, income countries 10 territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on Acknowledgements ...........................................11 maps represent approximate border lines for which there may not yet be full agreement. References ..................................................11 The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization or its Regional Office for Africa be liable Legislation in South Africa Intersectorial case study • Successful Tobacco for damages arising from its use. 1 Introduction Tobacco regulation in South Africa was not an overnight one-step measure, but rather, an organic process over several decades. The first tobacco law, the Tobacco Products Control Act, was passed in 1993, but amendments were regularly added to strengthen loopholes/concerns and will continue to be added in the future. This report provides a roadmap of the Tobacco Products Control Act of 1993, its subsequent regulations and amendments, and the intersectoral process undertaken to address the tobacco epidemic through legislation. It also illustrates the context of tobacco’s prevalence in South Africa, ranging from historical backgrounds to statistical data on smoking rates and smoking-related deaths. The report concludes with recommendations for other Low-and-Middle Income Countries (LMIC) using the South African tobacco narrative as an example. Methodology We conducted literature reviews using PubMed to search for articles that discussed tobacco’s prevalence and effects within the South African context. Key search words for the health implications of South African tobacco included, “smoking,” “South Africa,” “prevalence,” and “death rate.” We also searched the South African Medical Journal (SAMJ) using the same key search words. We screened titles and abstracts and read full texts of relevant articles. For government documents, we accessed government archives at info.gov.za and searched under “health-public health” for a list of acts and bills concerning tobacco regulations. For international comparisons, we searched WHO files and referred to the WHO Global Tobacco Reports from various years. Dr. Yussuf Saloojee, a veteran anti-tobacco 2 advocate and Director of the South African National Council Against Smoking, reviewed this report. 1. General background 1.1 Trends in smoking prevalence Smoking prevalence in South Africa (SA) has declined since the initiation of the first South African tobacco regulations in 1993. The prevalence rate is currently at 16.4% according to South African National Health and Nutrition Examination Survey (SANHANES-1) (1). Smoking prevalence, however, is not uniform in SA with respect to ethnicity, gender, age, and income. Tables 1 and 2 illustrate the differences in South African smoking prevalence across specified groups. Table 3 provides a comparison of smoking prevalence across Brazil, Russia, India and China, (BRICs) based on 2013 MPOWER findings. Prior to 1993, the smoking prevalence in SA was more or less within a consistent range across different age groups (~25%) and income levels (~33%), respectively. Following the initial tobacco regulations in 1993, the greatest decreases in prevalence rates occurred in both the youngest age group (16–24), as well as the lowest income-level tiers (ZAR 1–1399), suggesting price sensitivity with respect to tobacco taxes. TABLE 1: SMOKING PREVALENCE PERCENtages IN SOUTH TABLE 2: COMPARISON OF SMOKING PREVALENCE PERCENtages AFRICA BEFORE AND AFTER INITIAL TOBACCO REGULatIONS IN SOUTH AFRICA BY MONTHLY HOUSEHOLD INCOME 1993 2003 2010 Proportion of population Total 32.6 23.8 20.9 Monthly income level (1993) 1993 2003 Ethnicity ZAR 1–499 21.0 29.4 21.2 Coloured 50.9 43.9 42.9 ZAR 500–899 20.0 30.7 19.8 White 36.0 35.6 35.9 ZAR 900–1399 17.6 32.1 22.2 Indian 31.5 28.6 27.1 ZAR 1400–2499 14.5 33.2 24.8 Black 28.4 19.5 15.6 ZAR 2500–3999 9.0 34.6 25.7 Gender ZAR 4000–6999 9.2 35.6 27.4 Male 51.8 39.0 33.3 ZAR 7000–11999 5.8 34.4 31.5 Female 13.2 10.2 9.8 ZAR 12000+ 2.9 29.2 29.1 Age Adapted from van Walbeek (2). 16–24 28.0 17.0 — 25–34 25.7 27.9 — 35–49 25.5 30.6 — 50+ 20.8 20.7 — Adapted from van Walbeek (2) and SAARF/AMPS (3). TABLE 3: MPOWER 2013 TOBACCO SMOKING PREVALENCE PERCENtages ACROSS BRICs COUNTRIES Brazil russia india china south africa Prevalence: 15.0 34.0 12.0 23.0 14.0 Adapted from World Health Organization (4). 1.2 The health burden of tobacco In 2000, smoking ranked third as a risk factor for mortality in SA behind HIV/AIDS and hypertension. Smoking caused 8% of deaths (45,000 deaths a year) and 3.7–4.3% of Disability-Adjusted Life Years (DALYs)—a measure of morbidity and mortality (5). In comparison, about 25% of deaths in the United States and the United Kingdom were related to smoking in 2000 (6). SA’s smoking-related death rate appears to be relatively lower because tobacco use has only become common relatively recently (since the 1970s). The level of cigarette consumption in SA is lower than that of developed countries and SA experiences a general decreased life expectancy due to HIV/AIDS/TB. Intersectorial case study • Successful Tobacco Legislation in South Africa Intersectorial case study • Successful Tobacco 3 The relatively high rate of tobacco-related TB deaths is common in LMICs. Studies in China (7) and India (8) found that smokers had higher TB-related death rates than non-smokers. Smoking-related TB death is especially prevalent in SA and other Sub-Saharan African countries. In SA, higher TB rates are exacerbated by the HIV/AIDS situation, where 10% of the population is HIV positive (5, 9). Overall, smoking results in 58% of lung cancer deaths, 37% of chronic obstructive pulmonary disease deaths, 20% of TB deaths,