BY Christina Pitt
South Africa’s anti-smoking policies rely on increased sin taxes to cut smoking rates in the country. Experts say this is no longer enough, but people who use government facilities have very few other tools available to help them stop.
- Nicotine patches, pills and chewing gums are proven to increase a smoker’s chances of quitting. None of these are available to people who use South Africa’s state health facilities.
- South Africa signed the World Health Organisation Framework Convention for Tobacco Control, which means it has committed to rolling out national plans to help smokers quit. The country’s main anti-smoking policy is to hike sin taxes on tobacco products, but public health experts say it’s no longer enough.
- Researchers say it’s possible to give people more choices (such as patches) in South Africa. Community health workers could, for instance, distribute nicotine patches during routine home visits to help those who want to quit smoking — and counsel them.
“When I quit smoking, I was lying on the floor, shaking. I tried everything I could.”
This was Sam Filby’s experience eight years ago.
Co-founder of an app called ByeGwaai to help people quit smoking and a researcher at the University of Cape Town’s Research Unit for the Economics of Excisable Products (Reep), Filby, 30, says: “I wish I knew I didn’t have to go it alone.”
But it’s hard to kick the habit. That’s because tobacco contains nicotine, a chemical that causes your brain to release a feel-good hormone called dopamine. The pleasant feeling, however, doesn’t last very long, so your brain wants more. And the more often you give it a nicotine-induced fix, the more it needs to sustain that happy feeling. If you stop feeding the habit, you’re likely to feel grumpy, depressed or restless, have trouble sleeping, get headaches and have cravings for your go-to fix.
This is why many people who want to stop smoking fail. Studies show that most people reach for a cigarette again within eight days after they vowed to stop and only 3–5% of self-quitters (people who try to quit smoking without treatment) are still smoke free a year later. For many smokers it takes up to 30 tries to butt out.
Having signed the World Health Organisation’s Framework Convention on Tobacco Control, South Africa acknowledges that tobacco smoking is a public health concern. In 2016, researchers estimated that it led to 25 708 deaths among people between 35 and 74 years old. Moreover, the economy lost R42-billion to the habit in that year and 4% of the health department’s spending went to treating people for smoking-related illnesses.
But quitting needn’t be that hard — things like nicotine replacement therapy (NRT) and medicines can help, which is why the World Health Organisation’s (WHO) Essential Medicines List includes three pharmaceutical methods as aids to quit smoking.
Part of the government’s commitment to the WHO plan to curb smoking requires them to put in place programmes that will help people to quit, including pharmaceutical interventions.
But little is being done.
At the moment, the country’s policy to get people to stop lighting up a cigarette rests on raising a sin tax on tobacco products and implementing anti-smoking laws such as the Tobacco Products Control Act, which bans shops from selling smokes to under 18s and outlaws sponsorships and advertisements by tobacco companies. The law also forces tobacco manufacturers to print health warnings on their products.
Raising sin tax on tobacco products is a good way to curb smoking, with research showing that, on average, a 10% price hike will lead to 5% fewer people lighting up in low- and middle-income countries..
But, adds Corné van Walbeek, head of Reep, the 4.9% increase in sin tax on tobacco announced by Finance Minister Enoch Godongwana in February raises the amount of tax on a packet of cigarettes by only about a rand — from R19.82 to R20.80 — which, when the craving gets too much, is not a big enough deterrent for someone to stick it out.
It’s also easy to get a cheap fix in the country at the moment because of the growing illegal tobacco trade. In 2021, South Africans smoked 15.6-billion cigarette sticks for which the South African Revenue Service collected no sin tax. This means that the higher price tag that would have stopped some smokers from buying another box wasn’t there.
So, what options do South African smokers have who need the government’s help to quit?
Pills and patches
Neither NRT (in the form of gums and patches) nor the two quit-smoking pills on the WHO’s medicines list are available through South Africa’s state health facilities.
Nicotine gums and patches give your body small amounts of nicotine but without the other harmful effects of tobacco smoke. This way you don’t experience bad cravings or withdrawal symptoms and you can slowly start weaning yourself off the substance because your brain starts getting used to being happy without it.
The two types of pills, bupropion and varenicline, don’t contain any nicotine, but instead use the brain’s own chemistry to get you unhooked. Bupropion keeps dopamine circulating in your brain for longer than usual (it’s a type of drug called a norepinephrine dopamine re-uptake inhibitor) and so makes you feel happy without needing nicotine. When taken over about 10 weeks, starting with a single dose in the first week, and then two pills a day for the rest of the time, it helps one in five smokers to quit successfully.
Varenicline takes another approach. Instead of keeping you on a high for longer, it blocks some of the spots where nicotine would bind on nerve cells. In this way your brain still releases some dopamine when you smoke, but less than usual, which reduces the pleasure from smoking. Research shows that taking varenicline doubles someone’s chances to stop smoking.
The cost of quitting
Quitting is not only hard, it’s also expensive if you don’t want to go it alone.
A consumer survey in which 5 657 South African smokers participated showed that two-thirds were interested in using NRT aids, yet only two out of five have ever tried a pharmaceutical route (either NRT or medicines) in the past. According to the researchers’ calculations, using one nicotine patch a day for 12 weeks could cost between R9 000 and R21 500.
Using quit-smoking pills could cost someone between R1 250 and R1 650 for a full course (depending on whether they use bupropion or varenicline). These medicines are currently available by prescription in nearly 90 countries and the cost is partially or fully covered by the public health system in 45.
But they’re not included in South Africa’s Essential Medicines List, which means people who use state facilities can’t get them.
Cost is one of the things the National Essential Medicines List Committee considers when they decide whether a drug should be on the list or not.
The health department’s spokesperson, Foster Mohale, says that bupropion and varenicline have been considered for review by the committee, but adds that “their widespread use would always need to be recommended as part of an established smoking cessation programme.”
The chairperson of the school of health systems and public health at the University of Pretoria, Olalekan Ayo-Yusuf, says pills to help someone to stop smoking will only be prescribed if they are moderately to highly dependent on nicotine. (Someone’s dependence is determined according to the Fagerström Test of Nicotine Dependence — a score of between three and five means someone is moderately hooked on nicotine, while a score of six and up is considered a high dependence.)
Only about one in seven South African smokers have a high nicotine dependence, which seems to justify the government’s reticence to put the quit medicines on the list for state clinics.
Yet NRT and counselling are not included in the government’s approach either, which Ayo-Yusuf says “will be enough to help most smokers”.
In a study of 3 575 smokers, about one in six people who, for eight weeks, used a 25mg nicotine patch (about the strength that someone who smokes 10 or more cigarettes a day would typically use) managed to quit. Combining a patch with another form of NRT (such as lozenges) was even better, upping someone’s chance to kick the habit by up to 36%.
Even brief advice from a health worker (as little as three minutes) can give someone a 1.3 times better chance of quitting than without any counselling, research shows.
Anita Graham, head of pulmonology at Helen Joseph Hospital in Johannesburg, opened Gauteng’s first public sector smoking cessation clinic in 2021. They provided counselling, medicines and NRT free of charge using donor funds, but had to close down after a year because they ran out of money for medicines.
“We’ll never be able to get the clinic back up and running because we don’t have the finances to invest in the drugs and NRT, and our patients can’t afford it,” she says.
“All of these things cost money, and simply training staff is already very expensive. Without support from the government we won’t be able to continue.”
The pulmonologist Richard Van Zyl-Smit, who is also the founder of South Africa’s only operational smoking cessation clinic in the public health sector, at Groote Schuur Hospital in Cape Town, agrees that running a comprehensive quit programme, which would include medication and counselling, is expensive and time consuming. He says at his clinic, they offer counselling to patients only on referral, with little support from the government.
“We can see two or three patients a week — that’s the capacity. So it really isn’t a good model. What we need is a much larger process throughout the entire country.”
Can the government patch the gaps?
Rolling out a national cessation programme like what Van Zyl-Smit advocates for is not unrealistic — and in fact it’s something the WHO’s agreement asks of its signatories.
Uruguay has shown that it can be done. In 2008, the country put in place an all-round plan, which included providing tobacco dependence treatment and writing it into the national health plan. That was on top of laws that required 100% smoke-free spaces to be created in public areas, health warnings to be put on cigarette packs and tobacco adverts to be prohibited.
Smoking prevalence halved in five years, dropping from 18.4% in 2009 to 9.2% in 2014.
But implementation was not without challenges, such as a lack of money to pay healthcare workers and not having enough NRT patches.
Research confirms that poor healthcare infrastructure and low political priority can derail plans to roll out comprehensive programmes to help people quit tobacco in low- and middle-income countries.
Still, it’s not impossible, says Ayo-Yusuf, who helped formulate the part of the WHO framework about cessation programmes.
Rolling out expensive medicines is not necessarily needed, he says, as only a small percentage of smokers meet the requirements for this type of treatment.
However, NRT, is a good place to start, because it’s an over-the-counter intervention that could be handed out by community health workers (CHWs).
“Because getting NRT does not require a prescription, CHWs can be trained to handle it and it can be incorporated in the Ward Based Primary Healthcare Outreach programme,” he explains.
In this system, one outreach team leader (usually a nurse) leads a group of between six and ten CHWs, who serve a ward of 6 000 people. These teams operate in all 52 health districts across the country to look after people’s primary healthcare needs. They would, for instance, help people on tuberculosis or HIV treatment to take their medication correctly, support someone’s recovery from strokes, or contribute to programmes at childhood development centres.
Ayo-Yusuf says: “If these CHWs have NRT in their suitcases, they can reach many people during their visits — and provide counselling as well. The infrastructure is all there, we just need to use it.”
Filby agrees that the government’s inertia when it comes to implementing a comprehensive cessation plan is largely due to a poor understanding of smoking addiction.
“I understand that there are many competing interests like loadshedding and unemployment,” she says, “but they’re forgetting the long-term effects of chronic smoking-related diseases such as emphysema, which place a heavy burden on the public health sector.”
Filby says: “Smoking relapse is high, just like with every other addiction. Should we stop giving treatment to people with alcohol dependence or who have a heroin addiction? It’s cruel not to give smokers the tools to quit, because unlike other addictions tobacco kills slowly and quietly.”