Science-Led Regulations – The panacea to tobacco Harm Reduction in Africa

On December 11, 2022

Tobacco control in Africa remains a major factor in the Tobacco Harm Reduction (THR) equation. While there are no specific laws regarding the use and sale of safer nicotine products in most countries in the region, there is currently a blanket approach to regulation whereby safer nicotine products (SNP) such as e-cigarettes are being treated like combustible cigarettes.

In Sub-Saharan Africa region, 48 countries, only Eritrea, Malawi, Mozambique, Somalia and Sudan have not ratified the WHO’s Framework Convention on Tobacco Control. The WHO promotes the MPOWER tobacco control programme which requires countries to M monitor tobacco use, prevention policies; P protect people from tobacco smoke; O offer help to quit tobacco smoking; warn about the dangers of tobacco; E enforce bans on tobacco advertising, promotion and sponsorship; and R raise taxes on tobacco.

There is currently a lack of information on the availability of safer nicotine products on the market, except for nicotine replacement therapy (NRT). According to available data, the sale of snus is allowed in 22 countries, while there is no specific law for 26. For nicotine vaping products (e-cigarettes), there is no specific law for 38 countries, they are allowed under law in five countries and sale is banned in five.

In Ethiopia, Uganda, Gambia, Seychelles and Mauritius, electronic cigarettes are legal to use but illegal to sell though in 2019 the Seychelles government announced its intention to lift the ban and regulate electronic cigarettes. In the case of heated tobacco products, there are no specific laws for 44 countries, sale is allowed under law in three countries and banned in just one. In October 2020, the Kenyan government suspended the sale of LYFT nicotine pouches in order to review regulation. Since then, anti-tobacco harm reduction activists in Kenya have been pushing for either a complete ban of the product or for it to be regulated as a tobacco product (despite it not containing tobacco).

Speaking during a panel on scientific research and evidence-based regulation at the Second Edition of the Harm Reduction Exchange, Clive Bates, Director of Counterfactual Consulting firm said that current regulation was doing more harm than good to the health of smokers as they are being forced to get their nicotine from combustible cigarettes instead of safer nicotine options.

“The main policy concerns associated with regulating vaping, heated tobacco, pouches, snus and so on are the unintended consequences that come with a regulatory framework that will do more harm than good by essentially regulating in a not very smart way,” said Bates.

He added that one of the worst policies that is promoted by the World Health Organisation and the American Billionaire Foundations is simply to outlaw these alternative nicotine products all together.

“About 80% of smokers live in low and middle income countries, which essentially covers much of Africa and not South Africa, where risk reduced products are not available. It is deeply unethical to imagine that you would leave the most harmful products on the market and remove the least harmful. It makes no sense from a Public Health point of view and is unethical from a legal point of view. Nevertheless, that is what is being promoted by these groups.”

Evidence points to the fact that countries that have ratified the WHO Framework Convention on Tobacco Control (FCTC) and implemented nationwide bans of tobacco sale are currently experiencing numerous tobacco related challenges.

“These bans don’t really work. Bhutan for example banned the sale of Tobacco but they are now faced with a greater challenge, that of illegal traffic in tobacco and its products. So long as the demand within the country persists, it will continue to fuel the illicit market that has expanded since the ban of its sale in early 2000.

“Unfortunately, as studies indicate, Bhutanese youth are at the centre of this growing illegal trade in tobacco and its products. Not only are they using the product, they are actually involved in the criminal networks that supply them,” said Bates.

In an almost similar case, teenage smoking increased following an e-cigarette flavours ban in San Francisco.

Bates also highlighted some of the strategies being used to keep teenagers and young people away from vaping or partaking in Safer Nicotine Products and these range from fear driven advertising to taxation, amongst others. He added that the best way to tax safer nicotine products is by implementing risk proportionate taxation and regulation. He also said the focus should be more on consumer protection rather than deterring people from using safer and less harmful products.

Meanwhile, Dr Kgosi Letlape, president Africa Medical Association, said science was now being misrepresented leading to unscientific bans and regulations.

“We cannot ban these safe nicotine products because when we ban these products, we won’t know what is happening. When you look at Marijuana, when it was banned, we couldn’t even do research on the substance. Now that it is being legalised, you can do research on it. Now people have been allowed to extract the medicinal elements in cannabis.

“Just like what was done 10 years ago when pharmaceutical companies went in and extracted the nicotine and produced it in various forms such as gums, lozenges, patches etc. However, when nicotine was made available as an over the counter product, there was an outcry that something was wrong. Now science is being misrepresented through uninformed regulation,” said Dr Letlape.

He added that tobacco harm reduction was not a novel phenomenon in public health and there was need for collaboration between tobacco producers and the public health sector.

“The problem in tobacco is in how we frame managing tobacco. We framed it as a framework convention for tobacco control. We are stuck with trying to manage an old problem with old methodologies rather than trying to embrace innovation and the changing environment.

“The future is bright because anything that doesn’t have a cure, we can still reduce harm. We have don’t cure for diabetes but we reduce harm by advising patients on lifestyles management and using insulin and other drugs to manage blood sugar levels. There is no cure but we can reduce harm,” said Dr Letlape.

He added that the FCTC also refers to Harm Reduction even though there have been unending fights between public health and the tobacco industry.

“That is the elephant in the room and we need to ensure that those two parties come together and sit around the table so that we can find solutions moving forward. If you want to reduce harm, you have to get all parties together that are involved in harm. The harm producers, those that suffer harm and government should come together to reduce harm wherever possible.”

Of late, some stakeholders in South Africa have been pushing for heavy tax measures to mirror what has happened in Kenya where they are pushing for a complete ban of the risk reduced novel tobacco or nicotine delivery products or for them to be regulated as a tobacco product In January 2022 the National Treasury published a discussion paper outlining a proposal on the taxation of electronic nicotine and non-nicotine delivery systems (ENDS) which was made open for public comment. The draft Control of Tobacco Products and Electronic Delivery Systems bill regulates electronic cigarettes in the same way as cigarettes.