Sustaining success Submission on Bill B24-2006 to Portfolio Committee on Health

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Sustaining successSubmission on Bill B24-2006
to Portfolio Committee on Health

• Dr Yussuf Saloojee
• National Council Against Smoking

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Global cause of death

• There are only two major causes of death that are
  increasing rapidly worldwide - HIV and tobacco.

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Section 2 Control over smoking of tobacco
products
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The role of the law.

• A basic function of the law is to protect people
  from harm.
• The rights of the individual must be thus far
  limited, he must not make a nuisance of himself
• John Stuart Mill

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Passive smoking kills

• Over 900 scientific studies have linked passive
  smoking and ill health.
• It is a cause of lung cancer and heart disease in
  adult non-smokers.
• In children it increases the risk of sudden
  infant death syndrome (SIDS), acute respiratory
  infections (bronchitis and pneumonia), ear
  problems and asthma attacks.

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Short-term and long-term exposures can cause harm.

• Breathing tobacco smoke for as little as 30
  minutes can increase the risk of a heart attack
  in those with heart problems.
• Children, people with asthma, bronchitis, and
  heart disease are especially vulnerable.

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Total bans

• Countries with complete bans on smoking in indoor
  public places Ireland, Norway, Bhutan, New
  Zealand and Scotland.

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South Africa

• The 1999 Act prohibited smoking in all enclosed
  public places and workplaces, except in areas set
  aside for smokers.
• Overnight, social norms changed.
• Hospitals, clinics, schools, buses, taxis,
  offices, shopping malls rapidly became smokeless.

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• With the exception of some in the hospitality
  industry, the law is working well.
• The public (including smokers and non smokers)
  support the law.
• Ordinary people made the law work. They stood up
  for their right to clean air and most smokers
  respected that right.
• The law is self-enforcing. The police do not have
  to sit in every cinema, café, and office waiting
  to arrest offenders.

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The Proposed Amendments
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Restrictions on smoking near entrances to
enclosed public places

• Moving smokers a few metres away from entrances
  to buildings is no great inconvenience, but will
  prevent tobacco smoke polluting indoor areas.

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Smoking in day care centres and the entry of
minors into smoking sections.

• Young children are especially vulnerable to
  second-hand smoke.
• They are also less able to complain or move away
  from smoke-filled rooms.
• It is not possible to confine smoke to one area
  in a house. Even if smoking is restricted to a
  single room in the house, smoke will still drift
  throughout the home.

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• In smoking areas, where many people smoke, high
  levels of tobacco smoke toxins can build up, To
  take children into these places is recklessly
  exposing them to harm.

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Smoking in sports stadia and other crowded
facilities

• Smoking should be controlled in outdoor areas in
  which exposure cannot be easily avoided such as
  at railway platforms and sports stadia.
• In stadia exposure to tobacco smoke is likely to
  be sustained (from a few hours to the whole day
  for cricket lovers) and significant.

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Protecting workers constitutional rights

• Most people do not want to be exposed to tobacco
  smoke, but suffer in silence at work because they
  fear upsetting their employers.
• People must be able to voice their concerns
  without fear of repercussions.
• Employers must respect an employees right not to
  be forced to work in a smoking section against
  their wishes. People should not be required to
  pay with their health for the opportunity to
  work.

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What is not in the Bill and should be added.
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The special case of domestic workers

• The 1999 Act allows smoking in private homes.
  Private homes can be a workplace for domestic
  workers. They are not protected from tobacco
  smoke in smokers homes.
• The Act has created a situation where domestic
  workers are given less protection than other
  workers.

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Smoking in cars with child passengers

• Smoking in cars can produce high concentrations
  of smoke, especially if windows are closed.
• There is strong public support for a ban on
  smoking in cars while children are passengers.

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• SECTON 3A STANDARDS FOR MANUFACTURING AND EXPORT
  OF TOBACCO PRODUCTS

Slide 0
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• Death and disease from tobacco use can be
  decreased by
• reducing the number of people who use tobacco
• making tobacco products less dangerous by
  reducing their toxicity.

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Predicted and actual nicotine intakes per
cigarette
1.6
Health Survey for England 1998
1.4
1.2
1.0
Nicotine intake per cigarette (mg)
0.8
0.6
0.4
0.2
0 - .1
.1-
.2-
.4-
.5-
.6-
.7-
.8-
.9-
1.0
Cigarette nicotine yield (mg)
Actual
Predicted
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Predicted and actual nicotine intakes per
cigarette
1.6
Health Survey for England 1998
1.4
1.2
1.0
Nicotine intake per cigarette (mg)
0.8
0.6
0.4
0.2
0 - .1
.1-
.2-
.4-
.5-
.6-
.7-
.8-
.9-
1.0
Cigarette nicotine yield (mg)
Actual
Predicted
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Predicted tar intakes per cigarette
1.6
1.4
1.2
1.0
0.8
Tar intake per cigarette (mg)
0.6
0.4
0.2
0 - 1
1-
2-
4-
5-
6-
7-
8-
9-
10.
Cigarette tar yield (mg)
Actual
Predicted
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Brown Williamson (1979)

• Low tar cigarettes--
• Provide smokers with a choice and a reason not
  to quit.

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Low tar cigarettes
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Cigarette design

• The cigarette is more than just dried tobacco
  wrapped in paper, and snuff is not simply
  powdered tobacco leaf.
• The cigarette is a highly engineered product.

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Cigarette design

• Cigarette designed affects its appeal,
  addictiveness and safety.
• The cigarette is tailored to
• Maximize addiction,
• facilitate initiation and
• undermine cessation.

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Additives make it easier for children to start
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Making it easier for children to start

• Up to 1400 chemicals can be added to tobacco.
• An additive free cigarette is bitter, irritating
  to the throat and not easy to smoke.
• A smoother cigarette with a lighter taste can
  be produced by adding sweeteners like chocolate,
  licorice, and honey.
• In October, 2006 a tobacco company agreed to stop
  marketing candy and alcohol flavored cigarettes
  in the U.S, because of its appeal to children.
  The brands had names like Twista Lime and
  Mocha Mint.

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Making it more difficult to quit

• Ammonia changes the pH of smoke so increasing
  free nicotine levels. Free nicotine, passes
  more rapidly and completely through the lungs
  and has a faster effect on the brain.
• This makes it more difficult for smokers to quit.

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Deep inhalation

• Ventilated filters provide cooler and more dilute
  smoke. Larger quantities of smoke can be more
  deeply inhaled into the lungs.
• And the consequence is that low tar smokers are
  developing cancers further down in the lung.

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BAT (1979)

• the effect of switching to low tar cigarettes
  may be to increase, not decrease, the risks of
  smoking.

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Tobacco companies - an organized crime syndicate

• Cigarette makers lied to the public about the
  dangers of smoking and passive smoking
• marketed cigarettes to underage teenagers while
  falsely claiming that they had not done so
• manipulated nicotine levels to keep smokers
  hooked, while denying nicotine was addictive
• promoted the health benefits of light or
  low-tar cigarettes knowing these were no safer
  than ordinary cigarettes and
• destroyed and concealed documents to hide their
  illegal activities.
• US Judge Gladys Kessler, 2006.

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Too little regulation

• There are no legal restrictions on what may be
  added to tobacco products.
• Only the tobacco manufacturers know the additives
  used in each brand.
• New products can be introduced and the design of
  products can be changed with almost no regulatory
  oversight.

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By contrast

• Medications to help people quit smoking are
  strictly regulated by the Medicines Control
  Council.
• These have to meet the same safety and product
  standards as any other scheduled medicines and
  can only be sold through pharmacies.

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A crazy system

• Not regulating nicotine in its deadliest form
  (cigarettes), while strictly regulating it in its
  safest form (medications) is irrational.

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Regulatory Approach

• The law should
• Require full disclosure of all ingredients added
  to tobacco products.
• Enable government to order the removal of
  additives or design features which increase harm.

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Reducing the fire-risks from cigarettes

• Goal
• To reduce deaths, injuries and property damages
  resulting from fires started by manufactured
  cigarettes.
• Background
• About 1,400 fires (or 4) were caused by smoking
  in South Africa in 2004
• R45 million of property was destroyed.
• Falling asleep while smoking in bed or the
  tossing away of a lit cigarette can start a fire.

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• It is possible to reduce the likelihood that a
  lit cigarette will start a fire by altering its
  design.
• If not puffed upon for a while, cigarettes can
  be made to self-extinguish.
• New York State introduced Fire Safety Standards
  for Cigarettes 2004. Canada also has such laws.
• Self-extinguishing does not mean fire-safe. It
  is impossible to make a burning object completely
  fire-safe.

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Regulatory approach

• The Minister to set a performance standard that
  all cigarettes sold in South Africa must meet.
• This will require cigarettes to stop burning
  after a few minutes, if not puffed upon.
• Manufacturers may use a technical design of
  their choosing to achieve it.

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Snus
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Snus health effects

• Snus is less harmful than smoking.
• Snus may not cause lung disease or oral cancer.
• BUT it is not safe.
• Smokeless tobacco products contains about 28
  carcinogens

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Snus health effects

• Snus linked to pancreatic cancer, hypertension
  and type II diabetes.
• Risk to foetus, if used during pregnancy.
• Effects on patients with CVD??
• Snus is addictive and delivers high levels of
  nicotine.

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The great unknown

• Should smokeless tobacco products be promoted
  as potential harm-reduction products?

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Potential benefit of snus

• Switching to snus may reduce the risk of disease
  for smokers who have not quit.

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Potential risks of Snus

• The belief that snus is safe may
• - reduce quitting, encourage ex-users to
  restart.
• - encourage experimentation by children who
  would have avoided cigarettes.
• - promote increased tobacco use in those who
  have cut down.
• The public health benefits are uncertain.
• Create new health hazards in the process?

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What have we learned to this point?

• Experience with earlier generations of
  harm-reducing cigarettes suggests caution. .
• Government oversight and regulation is essential.

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Conclusion

• The Bill is fair, reasonable and workable.
• Freedom from addiction is a childs right and
  societys responsibility.
• Please put the freedom of children to grow up
  healthily above the freedom of an industry to
  market a deadly drug.

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Thank you