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As Covid-19 showed us, tobacco bans have little effect — behavioural changes work

As Covid-19 showed us, tobacco bans have little effect — behavioural changes work
Stefani Du Toit, Stephan Rabie, Casey Fredericks, Gameedah Slarmie, Mfanelo Ncukana, Nonkanyiso Molatoli, Roxanne Pelteret and John Joska
By Stefani Du Toit, Stephan Rabie, Casey Fredericks, Gameedah Slarmie, Mfanelo Ncukana, Nonkanyiso Molatoli, Roxanne Pelteret and John Joska
31 Aug 2023
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Research on consumption patterns during lockdown reveals that the overwhelming majority of tobacco consumers (91%) continued to use tobacco products despite the 250% price hike by some illicit traders.

Tobacco use is a major public health concern. In particular, smoking tobacco has been linked to a range of adverse health outcomes, including hypertension, diabetes and cancer.

To date, tobacco use has been regulated through the Tobacco Products Control Act 83 of 1993. Nonetheless, a transformative shift could be on the horizon for South Africa as the Tobacco Products and Electric Delivery Systems Control Bill, initially introduced by the Department of Health in 2018, inches closer to formal introduction.

For the most part, the new bill is largely aimed at the promotion of good public health practices in the South African context, which align with the best practices put forward by the World Health Organisation Framework Convention on Tobacco Control.

While this bill doesn’t entail a complete prohibition of tobacco or vaping products, as was seen during the Covid-19 pandemic, it will significantly restrict the promotion, advertising, sales, and use of tobacco products. Notably, the bill’s enactment will further restrict smoking in public spaces and enforce a complete prohibition of smoking in all indoor spaces.

Moreover, this prohibition will extend to private residences where children are present. The bill extends to e-cigarettes and/or vape-related products which fall within a grey area under the current smoking laws.

Draft bill backlash


Although the new laws are directed at the best interests of the public, the draft bill has been on the receiving end of backlash and opposition from both the tobacco and vaping industries since its initial proposal. Aside from the potential adverse implications for retailers specialising in tobacco or vape products, failure to abide by these laws can and will be viewed as a criminal offence with harsh consequences.

Such consequences include being liable to paying a fine, imprisonment for a period of up to three months, or both. Having received Cabinet approval for parliamentary submission, the draft bill is presently open for public input until Monday 4 September 2023.

Experience from the Covid-19 pandemic shows that even prohibition of certain products does not stop consumption. Despite the government's prohibition on alcohol, tobacco, and vaping items from March 27, 2022, to August 16, 2022, there is limited evidence supporting sustained positive impacts on tobacco use and alcohol use among South Africans.

Research on consumption patterns during the lockdown periods reveals that the overwhelming majority of tobacco consumers (91%) continued to use tobacco products despite the 250% price hike observed among certain illicit traders.

Of those individuals who did cease tobacco use during this period, 12% indicated an intent to resume use once the ban was lifted. Efforts to quit tobacco use may have been hindered by heightened anxieties and increased stressors amid this tumultuous period.

Read more in Daily Maverick: Feeling the Covid-19 blues and watching tobacco ban efforts going up in smoke

The effects of the prohibition, and the later restrictions placed on alcohol and tobacco products during the pandemic, offer valuable insight into the potential impact of the bill on tobacco use in the country — that is, that banning or restricting tobacco may not be enough to curb usage.

Currently, there is no data to suggest that the prohibition and restriction of tobacco products during the pandemic led to any long-lasting effects on tobacco use during or after the pandemic. As past events clearly illustrate, South Africans exhibit resourcefulness and a willingness to navigate unconventional avenues to procure tobacco and alcohol products beyond conventional means.

Cessation programmes in South Africa should not lean exclusively on a tobacco control framework; rather, they should be complemented by evidence-based behavioural interventions. Innovative strategies addressing the use of tobacco products represent a vital component missing from this intricate puzzle.

To truly make strides in curbing tobacco use, it’s crucial to supplement these laws in parallel with interventions that target behavioural change. These interventions can offer individuals the tools to understand and modify their behaviours, manage cravings, cope with triggers, and develop healthier coping mechanisms during stressful life events.

By addressing the root causes and ingrained patterns of tobacco use through behavioural interventions, we can potentially empower individuals with the skills needed to navigate the challenges of quitting and create sustainable, long-term changes in their tobacco use habits.

Kicking the habit


Here are why interventions targeting behavioural change are essential in curbing tobacco use:

First, behavioural interventions can address the root cause of tobacco use. For many people, smoking often arises from a variety of psychological factors such as stress, anxiety, and emotional triggers. While prohibition laws might discourage smoking in specific contexts, they fail to address the core issues driving this behaviour. Behavioural interventions delve into these underlying causes, helping individuals develop healthier coping mechanisms and emotional regulation skills.

Second, tobacco use not only leads to physical dependency but also becomes psychologically ingrained. Prohibition-type laws might curb access to tobacco products, but they do little to address the psychological dependency that drives cravings and relapse. Behavioural interventions hold the potential to equip individuals with strategies to manage these cravings, develop new habits, and strengthen their intent to quit.

For example, a novel nine-week intervention programme named QUIT, designed to simultaneously mitigate smoking and alleviate symptoms of anxiety and depression, has demonstrated promising results in the United States. QUIT effectively addresses smoking cessation, anxiety, and depression through a cohesive blend of components, including information highlighting the health benefits of quitting smoking, instruction in problem-solving skills, identification of triggers, and techniques to manage withdrawal symptoms.

A study evaluating the efficacy of QUIT demonstrated significant advantages in both the short term and long term. In this study, it was found that 46% of individuals who participated in the QUIT programme maintained abstinence at the six-month mark after quitting, in stark contrast to participants not receiving the QUIT programme (5%).

Third, laws alone often lack the power to instil lasting behavioural change. Even if access is restricted, individuals might find ways to bypass the restrictions or simply resume smoking once the ban is lifted — as seen in the case of the Covid-19 pandemic. Behavioural interventions focus on building skills, resilience, and self-efficacy making it more likely that individuals will successfully quit and maintain this accomplishment.

Last, relapse is a common challenge in quitting smoking. In fact, as many as 75% of individuals who attempt to quit smoking experience relapse within the first six months of cessation. However, behavioural interventions provide skills to identify high-risk situations, identify triggers, manage stress, and navigate social situations, reducing the risk of reverting to tobacco use.

As an example, the Cancer Association of South Africa (Cansa) provides a free online smoking cessation programme, eKick Butt Programme. This initiative offers individuals mentorship and support for quitting smoking via a sequence of emails, surveys, and downloadable resources.

Additionally, the World Health Organization launched a virtual “digital health worker” dedicated to assisting individuals in their journey to quit smoking. Utilising artificial intelligence, “Meet Florence” delivers guidance on overcoming the use of tobacco products, enhancing stress-management abilities, and adopting a healthier lifestyle.

While placing limitations on the promotion and sales of tobacco products might represent a step in the right direction, it does little to identify the individual physiological and psychological processes that drive the ongoing use of tobacco products.

Equipping individuals with the tools to navigate the cognitive and emotional challenges of tobacco dependency holds the promise of promoting robust reduction strategies and, ultimately, facilitating the cessation of tobacco use. DM

Stefani Du Toit and Dr Stephan Rabie are research psychologists and senior research officers in the HIV Mental Health Research Unit at the University of Cape Town. Casey Fredericks, Gameedah Slarmie, Mfanelo Ncukana, Nonkanyiso Molatoli and Roxanne Pelteret are interns in the Unit. Professor John Joska is Head of Clinical Services (psychiatry) at Groote Schuur Hospital and Director of the UCT HIV Mental Health Research Unit.

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