On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.99 n.2 Cape Town Feb. 2009
Quit smoking remedies hot favourites for EDL
With legislation allowing picture based health warnings on cigarette packs merely awaiting the president's signature, it has emerged that government is now considering placing nicotine replacement therapy (NRT) on the essential drugs list (EDL).
This was confirmed after the national department of health-hosted Third Conference of Parties to the WHO Framework Convention on Tobacco Control held in Durban last November.
In an interview with Izindaba, Dr Yussuf Saloojee, Executive Director of the National Council Against Smoking (NCAS), said NRT products including gum, patches, nasal spray and the antidepressant bupropion - all proven smoking reduction drugs - were up for EDL consideration.
One of South Africa's veteran smoking cessation experts, Saloojee said that even though these drug therapies worked best with behavioural support, 'they do increase success rates'. Cochrane reviews show that with behavioural support the 1-year success rate of pharmacotherapy increases smoking cessation from 15% to between 28% and 30%. 'These are not magic mushrooms, but they do increase success rates', Saloojee said.
With a conservatively estimated 44 000 South Africans dying annually from tobacco-related diseases, the EDL move has been welcomed as a positive step forward by South Africa, considered globally as among the top 15 countries with effective tobacco control measures.
The bill being considered for signature by President Kgalema Motlanthe (the final step before regulations are drawn up) allows the Minister of Health to issue regulations making picture-based public health warnings compulsory on all tobaccorelated products. It also levels the playing field around the compulsory manufacture of self-extinguishing cigarettes by adding importers to local tobacco product manufacturers. (Glowing cigarette butts are a leading cause of destructive and sometimes fatal runaway veld fires.)
Collaborative research by the Medical Research Council and the NCAS on what kind of warning pictures on cigarette packs will be most effective is due to begin early this year. The study will canvass the kind of pictures used on cigarette packs in 20 different countries. More importantly, it will involve surveying a nationwide cohort of urban, rural, old and young smokers to see whether pictures of diseased lungs, underweight babies in incubators or cuddly bears with captions urging no smoking in front of children - or a combination - work best.
The health department will use the results to inform its regulations. Saloojee emphasised: 'The bottom line is that the truth about tobacco is ugly. That's the issue; we're not trying to scare people into quitting but conveying the reality accurately in a way that people can easily understand'.
Asked about buproprion, he said that about 5 years ago psychiatrists in Europe using the drug to treat patients for depression found that their clients were more easily able to quit smoking. This prompted research confirming that the drug also acted on the dopamine system in the brain, reducing craving and, to a lesser extent, nicotine withdrawal symptoms.
No smoke where there's fiery political will
South Africa's wide-ranging antitobacco legislation is the result of three successive health ministers prioritising non-smoking as a powerful disease prevention lever.
Rina Venter introduced the Tobacco Products Control Bill in 1993 which made written health warnings on tobacco products compulsory, regulated smoking in public places and banned tobacco sales to people under the age of 16. Her successor, Nkosazana Zuma, in 1999 banned all advertising and the promotion of tobacco products, nationalised the ban on smoking in public places (previously left to individual local authorities, famously leading to tobacco magnate Anton Rupert threatening to withdraw his funding of the Cape Philharmonic Orchestra). Dr Manto Tshabalala-Msimang drove the legislation for picture warnings on cigarette products, tightened the indoor smoking ban to include partially enclosed areas, forced the disclosure of additives and ingredients and pushed for the manufacture of self-extinguishing cigarettes.
Asked what contact his organisation had with the tobacco industry, which has a highly sophisticated government lobbying machine, Saloojee replied, 'none'. 'They'll clearly try and stall the latest legislation. No, our goals are so completely different. There's no halfway place where we can agree to a set of goals - you need trust to have a relationship. It would be like asking the fox to build the chicken coop. They deliberately lied to people for 50 years, maintaining until 1988 that tobacco causes no diseases,' he added.
He claimed to have 'internal documents' showing that the local tobacco industry deliberately targeted children by using 'buzz or viral' marketing campaigns after the ad ban in 2000. These allegedly involved creating a word-of-mouth and SMS 'buzz' on the disco and club circuit about a top overseas underground band or a restaurant party (for example) where you had to be a smoker to gain entrance and free cigarettes were available at the venues.
Asked who funded his not-for-profit organisation, Saloojee declined to name names, saying only that it was 'private industry'. 'If we named them they would immediately be targeted by the tobacco industry,' he said.
If nicotine replacement therapy does get onto the EDL, some speedy lobbying of pharmaceutical companies will be necessary to avoid it becoming an elitist remedy for the addicted rich. Prices are European-based and one course of any of the NRT products will set addicts back as much as 3 months' worth of cigarette money.
Funders likely to cough up
Medical aids are unlikely to resist any NRT EDL moves, if the response from Heidi Kruger, spokesperson for the Board of Healthcare Funders is anything to go by. 'It will save money in the long term on the effects of nicotine abuse,' she said. She cautioned, however, that it was vital that the regulations giving effect to any new laws include a requirement that the drug be prescribed by a clinician.
'You can't have every corner supermarket selling patches, for example,' she added. The BHF had not yet done any impact studies but the reasoning on long-term disease prevention and cost prevention made logical sense, she said.
Fidel Hadebe, a spokesman for the national health department, said he was 'personally unaware' of NRT being considered for the EDL, but promised to make enquiries and get back to Izindaba. He failed to do so by the time of going to press several weeks later, in spite of an SMS reminder.