Medical Research Council
Public Hearings: Tobacco Products Control Amendment Bill Oral Submission by the Medical Research Council

Presented by: Dr A D MBewu
Executive Director of Research, MRC
Chairperson of the Science and Education Committee of SAMA Cardiologist and researcher in preventive cardiology

On behalf of the MRC's Comprehensive Tobacco Control Research Programme:
Dr Krisela Steyn (1)
Ms Priscilla Reddy (2)
Dehran Swart (2)
Dr Thea de Wet (3)

(1) Chronic Diseases of Lifestyle Programme
(2) National Health Promotion Research and Development Office
(3) The National Urbanisation and Health Research Programme

The Medical Research Council fully supports the proposed tobacco products control amendment Bill. The successful implementation of the proposed Bill will bring South Africa in line with the World Health Organisation (WHO) and the World Bank's recommendations for tobacco control for all the countries of the world and save hundreds of thousands of South Africans from premature deaths and disability in coming decades.

In all countries, a major cause of premature death is due to the excessive and inappropriate use of tobacco products. Cigarette smoke contains 43 known cancer-causing agents. Tobacco with high levels of nicotine is extremely addictive and it causes a large number of chronic diseases of lifestyle. The most common of these includes: tobacco-induced cancers (NB lung cancer); chronic obstructive lung diseases (chronic bronchitis and emphysema; cerebrovascular diseases (strokes) and ischaemic heart disease (heart attacks and angina).

GLOBAL BURDEN OF DISEASE DUE TO TOBACCO USE
Tobacco use has caused the death of 60 million people in the second half of the 20th century, which is more than the 50 million who died in World War II. In 1993 alone 3 million deaths due to tobacco were recorded globally and it has been projected that this figure would increase to ten million deaths per annum by 2025. Consequently tobacco addiction will have a major negative impact on the global economy due to this premature suffer and death. Tobacco is the major preventable cause of death in the twentieth century. Seventy percent of these deaths are expected to occur in developing countries. Half of lifelong smokers who start smoking in adolescence and continue throughout their lives will be killed by tobacco, and half of these will die before they are 60 years old when they should have being making a major contribution to the economy. Furthermore, these smokers will be dying on average 20 - 25 years earlier than they would have done if they did not smoke.

Among men aged 35 - 69 years in developed countries smoking is estimated to cause 25% of all deaths annually including:

* 45% of all cancer deaths
* 95% of lung cancer deaths
* 75% of chronic obstructive airways disease deaths
* 20% of vascular disease deaths
* 35% of deaths from heart attacks etc.

BURDEN OF DISEASE CAUSED BY TOBACCO IN SOUTH AFRICA
Tobacco use in South Africa is causing ever-increasing health problems and the number of tobacco-related deaths reported annually is increasing. In South Africa 25 450 smoking-related deaths were reported in 1988, about 10% of the total number of deaths. Tobacco use takes approximately 20 years to kill people who use it, therefore, current smoking death rates reflect smoking patterns of 20 years ago. These 1988 figures reflect smoking patterns of South Africans during the late 1960s and the death rates are likely to rise in the future as many more people smoke now in the country than did in the 1960s. This is well illustrated by the finding that from 1968 to 1988 there was a 300% increase in lung cancer deaths among coloured women and a 100% increase among coloured men and white women, all related to increases in smoking rates in these groups since the 1950s. In 1990 the highest rate of tobacco-related deaths (one in five) occurred in the Western Cape, where these high smoking rates have been present for decades in both men and women.

All South Africans are already affected as the following data show. Mzileni et al. (unpublished data) found in a study conducted in the Northern Province of South Africa between 1993 and 1995 that the male patients dying of lung cancer were 11 times more often smokers than other male patients of the same age at Garankuwa Hospital.

We are certain similar increases will be seen in the rest of South Africa over the next 20 years among African black people unless something is done now to prevent it. Already, smoking causes 13% of cancer deaths in developing countries (21% in males, 4% in females) and it is likely to rise to meet the levels found in the industrialised countries, where tobacco currently causes 28% of cancer deaths (42% in males 10% in females).

SMOMNG PATTERNS IN SOUTH AFRICA
Generally the smoking rates in the more affluent sector of the South African population have decreased during the last decade, while in the poorer sector the rates until recently was on the increase. This happened particularly where upward social mobility occurred in developing communities. Furthermore, studies by Steyn et al have shown that employed black South Africans have higher smoking rates than their unemployed counterparts, who do not have resources to purchase cigarettes. This raises a concern that smoking rates may indeed increase when employment improves in the country unless smoking is made less attractive than is currently the case. Similarly smoking until recently the suggestion was that the rates in young South Africans were on the increase and every effort had to be made to dissuade the young from taking up this killing habit.

From the most recent survey on smoking prevalence there is a strong suggestion that the Department of Health's initiatives to curb smoking in the country is yielding some results. The data suggests that the smoking rates in South Africa peaked around 1996, as Martin et all recorded a smoking rate for the country in1992 as 31.5%. By 1996 Reddy et al found in a national survey that 34% of adults or a total of seven million of the population of more than 43 million smoked cigarettes. This overall figure has increased by 1% per year since 1992, but the smoking rate among "Coloureds" has increased alarmingly by 12% over this 1992 figure. Also, there has been an increase in the prevalence of smoking among adults in five provinces when compared with the prevalence rates of the February 1995 survey.

This survey showed a more worrying pattern in the smoking pattern of the South African youths up to that time. The smoking prevalence in the 18 - 24-age-group has increased from 31% in February 1995 to 36% in October 1996. Invariably, most of the members in this group have become regular smokers during their adolescent years. Flisher and associates report that of their sample of 7 340 high school students in the Cape Peninsula, 18,1% smoked at least one cigarette per day. 10 Of the rest, 41,2% had experimented with cigarettes previously and 3,6% intended to start smoking. Of this group of smoking high school students 66,9% had tried to quit. These data again emphasize the need to protect the South African youth from being influenced in any way to take up smoking in their teenage years.

This increase in smoking rates seem to have turned around since 1997 when a market research company, SA Research Foundation recorded the 28% of South Africans smoked and provisional data from the recently completed South African Demographic and Health Survey found that 24% of South Africans reported that they smoked in 1998.

Since almost half of all South African households have smokers, exposure of children and nonsmokers to household environmental tobacco smoke has reached critical levels. In fact, of the 5-year-old children living in Johannesburg and Soweto, 64% was found to live with at least one smoker in the home. When children are exposed to environmental tobacco smoke, it has profound influence on their health. The study by Richards et al. showed that the prevalence of respiratory illness before and after the age of two years, respiratory symptoms, earache over the past year, low birth weight and learning difficulties were significantly increased in children exposed to parental smoke in the home, especially those exposed to maternal smoking. A recent article in Nature, one of the world's foremost scientific publications, reported that foetuses can passively smoke their fathers' cigarettes, causing mutations in their genes.

GLOBAL INDUSTRY PROMOTION OF TOBACCO
Despite the globally experienced harmful effects of smoking, the tobacco industry makes a large amount of money available for advertising and promoting their products. In the US alone during 1993, the tobacco industry spent $6.2 billion on tobacco advertising and promotion. This amount was nearly five thousand times more than the entire budget of WHO for tobacco or health activities in the same year.

ADVERTISING AND MARKETING OF TOBACCO PRODUCTS IN SOUTH AFRICA
Internationally the tobacco companies have been shown to target the developing countries for the promotion of tobacco products. This follows from the reduction of tobacco use in developed countries, where the informed public is reducing tobacco use in order to protect their health. Furthermore, analyses of tobacco advertising and promotional materials show that women and youth specifically are targeted in the developing countries. This will ensure that children growing up will become addicted and that the low smoking prevalence of women in most developing countries increases to levels found in men in these countries. 14 From a content analysis of South African tobacco advertisements it was seen that tobacco companies in South Africa have applied similar tactics in targeting women (Hooper, V. and Marks, A., 1996 personal communication). This is especially important in this country, where the smoking rates for "African" and "Indian" females are currently considerably lower than that of males.

One of the most important effects of this Bill will be to protect children and adolescents from becoming nicotine addicts.

Data from the Birth to Ten (BTT) study conducted in five- and seven-year-old children living in Johannesburg and Soweto showed the direct influence of advertising in general and specifically regarding tobacco brands in children. De Wet et al.'s provisional report on this study includes the following information:

During 1995 when the BTT children were 5 years old, 1 350 children from Soweto, Johannesburg were interviewed on their knowledge, perceptions and attitudes towards cigarette smoking. During 1997/98 the 5-year questionnaire plus additional questions were completed for 950 children, who are now 7 years old.

KEY FINDINGS Of BTT
60% of 5-year-old children were buying cigarettes for adults. When the question was repeated two years later, 55% were buying cigarettes for adults.

The Table below shows to what extent the children could recognise advertised names and logos of common South African products, particularly important in view or the amendment to the Bill that permits continued use of established logos.

Large numbers of 7-year-old children could recognise the brand names of commonly advertised South African products, including cigarettes and snuff.

7-year-old children could recognise advertised logo's of products, e.g. 78% of children recognised the Rothmans logo.

The high rate of Rothmans logo recognition is probably due to its indirect advertising through sports sponsorship, e.g. the National Soccer League Rothmans Cup NSL Rothmans Cup).

The high rate of recognition of the SA flag shows that young South African children can quickly incorporate new significant images.
Product name When name of product was mentioned, children could identify it (e.g. Rothmans = cigarette)
Consulate: 24%
Peter Stuyvesant: 61%
Rothmans: 47%
Ntsu (snuff): 36%
Boxer Tobacco: 4%
castle Lager: 73%
OMO: 95%
coca Cola: 99%
OK Bazaars: 34%
SA Flag: -

When logo of product was shown, children could identify it (e.g. OMO = soap powder)
consulate: 29%
Peter Stuyvesant: 47%
Rothmans: 78%
Ntsu (snuff): 49%
Boxer Tobacco: 6%
Castle Lager: 81%
OMO: 76%
Coca Cola: 83%
OK Bazaars: 72%
SA Flag: 97%

These data suggest that there is an urgent need for the full implementation of WHO recommendations for comprehensive tobacco control in South Africa. This includes providing effective protection from involuntary exposure to tobacco smoke in transit vehicles, public places and workplaces; and a ban on all forms of tobacco advertising, promotion and sponsorship to protect South Africans, including the children, from being encouraged to use a product that will kill them 20 years earlier than necessary if it is used as the manufacturers suggest

CONCLUSION
This Bill is in line with legislation from many other countries, as governments realise the importance of complete bans on tobacco advertising, promotion and sponsorship; creating smoke-free public places; prohibiting free distribution of cigarettes and reducing the harmful substances in tobacco.

We are confident that if you pass this Bill in its present form you will save hundreds of thousands of South Africans in coming decades an untimely and very unpleasant death.