COVID-19 and a temporary ban on tobacco sales in South Africa: impact on smoking cessation

OBJECTIVE

To evaluate the impact of COVID-19 plus a temporary ban on the sale of tobacco and vaping products, on smoking cessation in South Africa, by reviewing research surveys conducted while the prohibition was in place.

METHOD

An internet search was conducted on 20 August 2020, using the key words: 'South Africa', 'survey', 'poll', 'smoking', 'cigarettes', 'tobacco", 'vaping', and 'COVID-19'. There were no language restrictions. Additional studies were identified through press reports. Only studies conducted between March and August 2020 were included.

RESULTS

Four surveys which reported on smokers quitting behaviour were included. None had been published in a peer reviewed journal. The heterogeneity of the data did not allow pooling. Support for the ban on tobacco sales amongst smokers varied from 6% to 36%. Similarly, there were inconsistent findings about quitting behaviour. Nationally, between 16% to 49% of smokers reported not smoking during the ban.

CONCLUSIONS

Cigarette smoking in SA dropped during the 2020 COVID-19 lockdown, but the estimates were inconsistent, probably because of survey design. There was evidence that the lockdown achieved the fastest rate of decline in smoking prevalence in the country's history. The true extent of the fall though is uncertain. Prevalence studies post lockdown, using probability sampling, may more accurately show how many people quit smoking.

Introducing an Ethics Framework for health priority-setting in South Africa on the path to universal health coverage

BACKGROUND

South Africa (SA) has embarked on a process to implement universal health coverage (UHC) funded by National Health Insurance (NHI). The 2019 NHI Bill proposes creation of a health technology assessment (HTA) body to inform decisions about which interventions NHI funds will cover under UHC. In practice, HTA often relies mainly on economic evaluations of cost-effectiveness and budget impact, with less attention to the systematic, specific consideration of important social, organisational and ethical impacts of the health technology in question. In this context, the South African Values and Ethics for Universal Health Coverage (SAVE-UHC) research project recognised an opportunity to help shape the health priority-setting process by providing a way to take account of multiple, ethically relevant considerations that reflect SA values. The SAVE-UHC Research Team developed and tested an SA-specific Ethics Framework for HTA assessment and analysis.

OBJECTIVES

To develop and test an Ethics Framework for use in the SA context for health priority-setting.

METHODS

The Framework was developed iteratively by the authors and a multidisciplinary panel (18 participants) over a period of 18 months, using the principles outlined in the 2015 NHI White Paper as a starting point. The provisional Ethics Framework was then tested with multi-stakeholder simulated appraisal committees (SACs) in three provinces. The membership of each SAC roughly reflected the composition of a potential SA HTA committee. The deliberations and dedicated focus group discussions after each SAC meeting were recorded, analysed and used to refine the Framework, which was presented to the Working Group for review, comment and final approval.

RESULTS

This article describes the 12 domains of the Framework. The first four (Burden of the Health Condition, Expected Health Benefits and Harms, Cost-Effectiveness Analysis, and Budget Impact) are commonly used in HTA assessments, and a further eight cover the other ethical domains. These are Equity, Respect and Dignity, Impacts on Personal Financial Situation, Forming and Maintaining Important Personal Relationships, Ease of Suffering, Impact on Safety and Security, Solidarity and Social Cohesion, and Systems Factors and Constraints. In each domain are questions and prompts to enable use of the Framework by both analysts and assessors. Issues that arose, such as weighting of the domains and the availability of SA evidence, were discussed by the SACs.

CONCLUSIONS

The Ethics Framework is intended for use in priority-setting within an HTA process. The Framework was well accepted by a diverse group of stakeholders. The final version will be a useful tool not only for HTA and other priority-setting processes in SA, but also for future efforts to create HTA methods in SA and elsewhere.

Estimating the burden of disease attributable to smoking in South Africa in 2000

OBJECTIVES

To quantify the burden of disease attributable to smoking in South Africa for 2000.

DESIGN

The absolute difference between observed lung cancer death rate and the level in non-smokers, adjusted for occupational and indoor exposure to lung carcinogens, was used to estimate the proportion of lung cancer deaths attributable to smoking and the smoking impact ratio (SIR). The SIR was substituted for smoking prevalence in the attributable fraction formula for chronic obstructive pulmonary disease (COPD) and cancers to allow for the long lag between exposure and outcome. Assuming a shorter lag between exposure and disease, the current prevalence of smoking was used to estimate the population-attributable fractions (PAF) for the other outcomes. Relative risks (RR) from the American Cancer Society cancer prevention study (CPS-II) were used to calculate PAF.

SETTING

South Africa.

OUTCOME MEASURES

Deaths and disability-adjusted life years (DALYs) due to lung and other cancers, COPD, cardiovascular conditions, respiratory tuberculosis, and other respiratory and medical conditions.

RESULTS

Smoking caused between 41,632 and 46,656 deaths in South Africa, accounting for 8.0 - 9.0% of deaths and 3.7 - 4.3% of DALYs in 2000. Smoking ranked third (after unsafe sex/ sexually transmitted disease and high blood pressure) in terms of mortality among 17 risk factors evaluated. Three times as many males as females died from smoking. Lung cancer had the largest attributable fraction due to smoking. However, cardiovascular diseases accounted for the largest proportion of deaths attributed to smoking.

CONCLUSION

Cigarette smoking accounts for a large burden of preventable disease in South Africa. While the government has taken bold legislative action to discourage tobacco use since 1994, it still remains a major public health priority.

The influence of maternal cigarette smoking, snuff use and passive smoking on pregnancy outcomes: the Birth To Ten Study

This article describes the patterns and effects of maternal snuff use, cigarette smoking and exposure to environmental tobacco smoke during pregnancy on birthweight and gestational age, in women living in Johannesburg and Soweto in 1990. A cohort of 1593 women with singleton live births provided information about their own and household members' usage of tobacco products during pregnancy. The women completed a questionnaire while attending antenatal services. Data on gestational age and birthweight were obtained from birth records. Women who smoked cigarettes or used snuff during pregnancy accounted for 6.1% and 7.5% of the study population respectively. The mean birthweight of non-tobacco users was 3148 g [95% CI 3123, 3173] and that of the smokers 2982 g [95% CI 2875, 3090], resulting in a significantly lower mean birthweight of 165 g for babies of smoking mothers (P = 0.005). In contrast, women using snuff gave birth to infants with a mean birthweight of 3118 g [95% CI 3043, 3192], which is a non-significant (P = 0.52) decrease (29.4 g) in their infants' birthweights compared with those not using tobacco. A linear regression analysis identified short gestational age, female infant, a mother without hypertension during pregnancy, coloured (mixed racial ancestry), and Asian infants compared with black infants, lower parity, less than 12 years of education and smoking cigarettes as significant predictors of low birthweight, while the use of snuff during pregnancy was not associated with low birthweight. The snuff users, however, had a significant shorter gestational age than the other two groups of women. The birthweight reduction adjusted for possible confounders was 137 g [95% CI 26.6, 247.3 (P = 0.015)] for cigarette smokers and 17.1 g [95% CI -69.5, -102.7, P = 0.69] for snuff users respectively, compared with the birthweight of non-tobacco users. Among women who did not smoke cigarettes or use snuff, exposure to environmental tobacco smoke did not result in significant effects on the birthweight of their infants. In conclusion, infants of cigarette smokers had significantly lower birthweights than those of non-tobacco users or snuff users who are exposed to nicotine during pregnancy. Passive smoking did not affect birthweight significantly in this population.

Psychologists and tobacco: attitudes to cessation counseling and patterns of use

BACKGROUND

Psychologists can play an important role in helping their clients stop using tobacco. The extent to which they do so, or quit themselves, has not been reported previously. The utility of snus in reducing smoking prevalence is also questioned and merits study.

METHOD

A 36-item self-completion questionnaire was mailed to a random sample of 1000 Swedish psychologists.

RESULTS

The response rate was 85%. Very few psychologists (1%) 'often' helped clients to stop using tobacco. While a majority (72%) believed that quitting tobacco use would improve their client's quality of life, most (75%) thought that it was not their responsibility to help clients stop and 74% felt they lacked the necessary skills. About 8% of psychologists smoked cigarettes daily. Use of snus as an aid to cigarette cessation was common in men, but not women, although overall, the percentage of smokers who had quit smoking (72%) did not differ by gender.

CONCLUSIONS

Most Swedish psychologists have stopped smoking, but very few help their clients to quit. Targeted campaigns aimed at encouraging and supporting psychologists to treat nicotine dependence are needed. This could increase cessation rates in the population. Snus helped reduce smoking prevalence among men and is a potentially useful harm reduction tool.

Tobacco use in South Africans during 1998: the first demographic and health survey

OBJECTIVE

To determine smoking patterns in South Africa, and to identify groups requiring culturally appropriate smoking cessation programmes.

METHODS

A random sample of 13,826 people (> 15 years), was interviewed to identify tobacco use patterns and respiratory symptoms. Peak expiratory flow rates were measured. Multinomial regression analyses identified sociodemographic factors related to tobacco use, and the latter's association with respiratory conditions.

RESULTS

In 1998, 24.6% adults (44.2% of males and 11.0% of females) smoked regularly. Coloured women had a higher rate (39%) than African women (5.4%). About 24% of the regular smokers had attempted to quit, with only 9.9% succeeding. African women (13.2%) used smokeless tobacco more frequently than others. Of the nonsmokers 28% and 19% were exposed to environmental tobacco smoke in their homes and workplaces, respectively. The regression analysis showed that the demographic characteristics of light smokers (1-14 tobacco equivalents per day) and heavy smokers (> or = 15 tobacco equivalents per day) differed. Light smoking occurred significantly more frequently in the poorest, least educated and urban people. The relative risk for light smoking was 18 in Coloured women compared with African women. Heavy smoking occurred most frequently in the highest educated group. A dose-response was observed between the amount smoked and the presence of respiratory diseases.

CONCLUSIONS

Smoking in South Africa is decreasing and should continue with the recently passed tobacco control legislation. Culturally appropriate tobacco cessation programmes for the identified target groups need to be developed.

[Fatal deception: the tobacco industry's "new" world standards for tobacco marketing]

Being increasingly threatened by the worldwide antismoking struggle, the major tobacco companies are eager to improve their public image. This leads the companies to adopt inconsequential "measures" such as the tobacco industry's "new" standards for tobacco marketing that were "voluntarily" issued in September 2001 by the British American Tobacco company. These measures are clearly attempts to reduce the disapproval generated by the companies' promotion and advertising campaigns, which indirectly target young people. With these standards the tobacco companies supposedly commit themselves, among other things, to not using advertising directed at youth and to not selling or distributing tobacco products in places frequented by young people. This document explains why these measures are completely ineffective, are not anything new, and are a subtle effort to feign a conscientious, responsible attitude, which is far from genuine. As long as there are marketing activities directed at adults, young people will be exposed to the influence of those activities. Many countries have completely prohibited the marketing of tobacco products, given that the "new" marketing standards do not represent progress in any way whatsoever.

Tobacco industry tactics for resisting public policy on health

The tactics used by the tobacco industry to resist government regulation of its products include conducting public relations campaigns, buying scientific and other expertise to create controversy about established facts, funding political parties, hiring lobbyists to influence policy, using front groups and allied industries to oppose tobacco control measures, pre-empting strong legislation by pressing for the adoption of voluntary codes or weaker laws, and corrupting public officials. Formerly secret internal tobacco industry documents provide evidence of a 50-year conspiracy to "resist smoking restrictions, restore smoker confidence and preserve product liability defence". The documents reveal industry-wide collusion on legal, political and socially important issues to the tobacco industry and clearly demonstrate that the industry is not disposed to act ethically or responsibly. Societal action is therefore required to ensure that the public health takes precedence over corporate profits. Recommendations for reducing the political influence of the tobacco industry include the following. Every tobacco company in every market should publicly disclose what it knew about the addictiveness and harm caused by tobacco, when it obtained this information, and what it did about it. The industry should be required to guarantee internationally recognized basic consumer rights to its customers. Trade associations and other industry groupings established to deceive the public should be disbanded. These recommendations should be incorporated into WHO's Framework Convention on Tobacco Control.

All Africa conference on tobacco control

Although the health hazards of smoking are now generally accepted in most Western countries, the arguments have not had much impact on poorer nations. A conference on tobacco control held in Harare, Zimbabwe, in November last year was the largest to tackle this problem. The conference heard how threats of epidemics of tobacco related disease in the distant future held little weight with governments of countries that often already had massive public health problems. More immediate effects needed to be emphasised. Speakers gave three cogent arguments; firstly, the loss of capacity for foreign trade in essential goods, since most African countries are net importers of tobacco; secondly, the extensive deforestation which is occurring to fuel the flue curing of tobacco; thirdly, evidence from Papua New Guinea that raising taxation on tobacco provides governments with increased income for many years before a decrease begins.

Comparison of tests used to distinguish smokers from nonsmokers

Questionnaire and biochemical measures of smoking were studied in 211 hospital outpatients. Eleven different tests of smoke intake were compared for their ability to categorize smokers and nonsmokers correctly. The concentration of cotinine, whether measured in plasma, saliva, or urine, was the best indicator of smoking, with sensitivity of 96-97 per cent and specificity of 99-100 per cent. Thiocyanate provided the poorest discrimination. Carbon monoxide measured as blood carboxyhaemoglobin or in expired air gave sensitivity and specificity of about 90 per cent. Sensitivities of the tests were little affected by the presence among the claimed nonsmokers of a group of 21 "deceivers" who concealed their smoking. It is concluded that cotinine is the measure of choice, but for most clinical applications carbon monoxide provides an acceptable degree of discrimination and is considerably cheaper and simpler to apply.

Reduction of tar, nicotine and carbon monoxide intake in low tar smokers

Blood nicotine, cotinine, and carboxyhaemoglobin (COHb) concentrations were measured in 392 smokers (255 women and 137 men) of "middle tar" (17-22 mg), "low to middle" (11-16 mg), and "low tar" (less than 11 mg) cigarettes. Since tar intake cannot yet be measured directly, we devised an index to estimate it based on the use of measured levels of an intake marker (eg, blood nicotine) and the ratio of the tar to marker yields of the cigarettes. This approach was validated by its ability to enhance the prediction of levels of one marker by use of another. In a practical test, using COHb and the CO/nicotine yield ratio of the cigarettes, the mean blood nicotine concentration of the low tar smokers was predicted to be 31.9 ng/ml compared with the measured mean of 31.8 ng/ml. Our main findings were that despite substantial compensatory increases in inhalation, the low tar smokers took in about 25% less tar, about 15% less nicotine, and about 10% less carbon monoxide than smokers of middle and low to middle tar cigarettes. These results indicate that low tar cigarettes of the type available in Britain since the late 1970s are likely to prove less harmful than other brands. Monitoring of smoke intakes could supplement epidemiological approaches and provide earlier evidence of whether changing cigarette designs lead to any significant dosage reduction that could affect the risk of disease.

Relationship between cigarette yields, puffing patterns, and smoke intake: evidence for tar compensation?

The relationship between cigarette yields (of nicotine, tar, and carbon monoxide), puffing patterns, and smoke intake was studied by determining puffing patterns and measuring blood concentrations of nicotine and carboxy-haemoglobin (COHb) in a sample of 55 smokers smoking their usual brand of cigarette. Regression analyses showed that the total volume of smoke puffed from a cigarette was a more important determinant of peak blood nicotine concentration than the nicotine or tar yield of the cigarette, its length, or the reported number of cigarettes smoked on the test day. There was evidence of compensation for a lower tar yield over and above any compensation for nicotine. When nicotine yield was controlled for, smokers of lower-tar cigarettes not only puffed more smoke from their cigarettes than smokers of higher-tar cigarettes but they also had higher plasma nicotine concentrations, suggesting that they were compensating for the reduced delivery of tar by puffing and inhaling a greater volume of smoke. The results based on the COHb concentrations were consistent with this interpretation. If an adequate intake of tar proves to be one of the main motives for smoking, then developing a cigarette that is acceptable to smokers and also less harmful to their health will be much more difficult.

Carboxyhaemoglobin and plasma thiocyanate: complementary indicators of smoking behaviour?

Carboxyhaemoglobin and plasma thiocyanate concentrations were measured in 79 non-smokers and 360 cigarette smokers. The mean levels were 0.73% and 7.09% carboxyhaemoglobin and 40 . 2 and 133 . 8 mumol thiocyanate/1 plasma respectively. With 1 . 6% carboxyhaemoglobin and 73 . 0 mumol thiocyanate/1 plasma as critical values the concentrations of carboxyhaemoglobin in 96.6% of subjects and of thiocyanate in 93.4% were compatible with reported smoking status. This difference between the two tests is significant (p less than 0 . 005). Statistical combination of the carboxyhaemoglobin and thiocyanate results, with the use of linear discrimination analysis, only marginally improved their diagnostic efficiency (96.8% of subjects were grouped correctly). This analysis did, however, successfully regroup 21 of 26 individuals with contradictory carboxyhaemoglobin and thiocyanate classifications. It is concluded that in this study determination of thiocyanate added little to the information obtained from carboxyhaemoglobin measurements alone.

Blood carboxyhaemoglobin, plasma thiocyanate, and cigarette consumption: implications for epidemiological studies in smokers

Carboxyhaemoglobin and plasma thiocyanate concentrations were found to be significantly correlated with self-reported daily cigarette consumption in 360 smokers (r = 0.416 and 0.412 respectively; p less than 0.001). The extent to which inhalation patterns affected the intake of cigarette smoke constituents was determined from the partial correlation between carboxyhaemoglobin and plasma thiocyanate concentrations after the number of cigarettes smoke per day had been allowed for (r = 0.48). Thus 23% of the variation in carboxyhaemoglobin and thiocyanate concentrations was accounted for by the was a cigarette was smoked and a further 21% by the number smoked a day. Furthermore, the relation between carboxyhaemoglobin or plasma thiocyanate and daily cigarette consumption was not linear but reached an asymptote at consumption rates above 25 cigarettes a day. These results suggest that by itself daily cigarette consumption will not identify those smokers most at risk and will also underestimate and dose-response relationship between smoking and selected diseases.

The evaluation of a photometer (the Radiometer OSM2) for the determination of haemoglobin concentration and per cent oxyhaemoglobin and carboxyhaemoglobin in blood

Haemoglobin concentration and its saturation with oxygen and carbon monoxide were estimated in identical blood samples using an automated two-wavelength photometer (the Radiometer OSM2) and standard methods. The instrument was easy to operate and maintain and, in general, was accurate and repeatable. At carboxyhaemoglobin levels below 1.5%, however, the precision of the instrument was poor.

Nitrous oxide concentrations in the dental surgery, Atmospheric and blood concentrations of personnel

Pollution in the dental outpatients surgery was assessed by measuring atmospheric nitrous oxide levels and comparing these with the venous blood concentrations in the operator-anaesthetist and his assistant. The effects of scavenging on both measurements have also been determined. Without scavenging the nitrous oxide level in the blood of the dentist was over four times that of the average anaesthetist working in an operating theatre. Some of the factors contributing to these high levels, and the effectiveness of scavenging are discussed.

Blood concentrations of nitrous oxide in theatre personnel

Blood concentrations of nitrous oxide were measured in anaesthetists, surgeons and theatre nurses. Comparison of anaesthetists and surgeons working in the same theatre showed that in ENT surgeons concentrations were greater (P < 0.01), while in general surgeons they were smaller (P < 0.003). Blood concentrations of nitrous oxide in the "circulating" nurses were low; with scavenging they were unmeasurable. Atmospheric concentrations in the breathing zones were usually greater than the corresponding blood concentrations, but this was not always true. However, a positive correlation between blood and atmospheric concentrations was obtained (r = 0.82). Meticulous use of scavenging devices produced a mean reduction in blood nitrous oxide concentrations of 86% for all groups. The mean blood concentration of nitrous oxide in anaesthetists when scavenging was used was 45 p.p.m. (1.9 micromol/litre). This figure should be taken into account in establishing maximum permitted exposure to nitrous oxide.

Smokers' response to shortened cigarettes: dose reduction without dilution of tobacco smoke

This study was designed to examine the response of smokers to shortening their usual brand of cigarettes. The shortening reduces the dose of smoke available from each cigarette without affecting concentration and therefore differs from dose reduction by dilution, which occurs when smokers switch to cigarettes with lower tar and nicotine deliveries. Measures of smoking behavior (e.g., cigarette consumption, puff rate), mouth-level nicotine intake (calculated from butt content), and intake to the lungs (plasma nicotine and COHb) were made in 10 smokers after 48 hr ad libitum smoking of full, three-quarter, and half-length cigarettes in a Latin square design. Mouth-level smoke intake was maintained on shortened cigarettes due to a combination of 2 types of compensatory maneuver: (1) by increasing the intensity of puffing and thereby extracting proportionately more of the smoke available from each cigarette and (2) by smoking more cigarettes. The amount of smoke inhaled, on the other hand, was only partially maintained (58% compensation). This was achieved by increase in cigarette consumption alone. There was achieved by increase in cigarette consumption alone. There was no evidence of any compensatory increase in the amount of smoke inhaled from each cigarette. Increase in consumption was thus the only maneuver that contributed to maintaining smoke intake at lung level; mouth-level intake was regulated by increasing intake per cigarette as well as consumption.

Blood levels of nitrous oxide during bronchoscopy

Arterial blood levels of nitrous oxide have been measured during bronchoscopy using two types of ventilating bronchoscope. It seems unlikely that the blood levels of nitrous oxide achieved using these devices would contribute to a reduction in the incidence of awareness during this procedure.

Estimation of nitrous oxide in blood. Gas chromatographic analysis of trace or analgesic levels

The estimation of nitrous oxide (N20) at trace and analgesic levels in whole blood is described. A micro-ionisation cross section (MICS) detector was used to measure trace levels of N2O (0.69 to 17.88 mumol N20/litre of blood); whilst a thermal conductivity (TC) detector was used to determine levels from 0.17 to 13.34 mmol N20/litre of blood. The coefficient of variation was 1.3% and 3.2% for the TC and MICS detectors respectively. The technique equals the precision of previously described methods but is considerably quicker. It appears to be suitable for use in the measurement of blood levels of N20 in both theatre personnel and patients undergoing anaesthesia.

Nicotine chewing gum as a substitute for smoking

The capacity of nicotine-containing chewing gum to produce plasma nicotine levels comparable to heavy cigarette smoking was tested in 21 subjects. On a fixed schedule of one piece of gum (4 mg nicotine) per hour, the average peak plasma nicotine concentration was 175-7 nmol/l (28-5 ng/ml) compared to 189-3 nmol/l (30-7 ng/ml) obtained from normal ad libitum smoking. Unpleasant side effects were common and in some cases plasma nicotine concentrations were two and even three times as high as with smoking; The chewing gum provided some satisfaction to all but four subjects, but its degree was not related to the concentration of plasma nicotine it produced, neither was there an inverse relation between the plasma nicotine concentration while taking the gum and the subjective sense of missing cigarettesmthis suggests that the capacity of the gum to act as a substitute for smoking is not necessarily related to its capacity to provide nicotine. Flexible dosage dictated by individual needs would probably lower the incidence of side effects and might secure closer approximation to smoking concentrations of plasma nicotine.