Policy discussion: How to promote harm reduction in policy making

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Does re-thinking the regulation of tobacco and nicotine products have the potential to transform public health in South Africa? Would a dispensation on reduced harm products help South African smokers who continue to smoke and in what way? Would such a regulation really encourage smokers to switch to less harmful alternatives? A panel consisting of Professor Solomon Rataemane, Head of Department of Psychiatry at Sefako Makgatho Health Sciences University, Dr Kgosi Letlape, an ophthalmologist in private practice and health activist and co-founder of the African Harm Reduction Alliance, Marcelo Nico, Managing Director at Philip Morris Southern Africa and Indian Ocean Islands, Professor Daniel Malan, Director for Corporate Governance at Stellenbosch University and Coenraad Bezuidenhout, Managing Director of Public Affairs and Government Relations Advisory at FTI Consulting debate the issue. The third segment of a panel discussion looking at harm reduction in tobacco control policy.

Click here for Part Two – Global examples of harm reduction and lessons for SA

Coenraad Bezuidenhout: Prof Rataemane is harm reduction or reduced harm product innovation something that needs to be accommodated or is it something that policy should actively promote?

Prof Rataemane: Policy has to promote harm reduction; we have to find a way of presenting the notion of harm reduction in a way that is less suspicious, and which is actually a truthful way of intervening in preventing further harm.

I think our issue really is positioning the concept of harm reduction not as a vague concept. You may have the people who quit for instance, or the people who continue enjoying or using or accessing nicotine in various forms. What we are saying is we can provide nicotine in a safer way – and that is harm reduction.

Coenraad Bezuidenhout: In certain areas in the community there may be fears that these reduced harm products will draw new consumers into tobacco consumption. 

Dr Letlape: Well just use the snus experience, when you read the literature the same thing was said about snus 60 years ago – that it could be a gateway to smoking. What is actually the experience over those 30 – 40 years [in these markets] is that snus has displaced smoking.

Coenraad Bezuidenhout: Does this accord with the experience of the industry?

Marcelo Nico: First of all, all of our reduced risk products are developed and commercialised for current smokers. We focus on the current smoker that intends to continue to smoke, who, instead of burning the tobacco can heat the tobacco, and who can use e-cigarettes or other means.

When we talk about South Africa, we have 7 million smokers, some of them will quit, but what happens to the millions that will continue to smoke – then giving them alternatives is our focus. The majority of the information that is available today, does not indicate an initiation from e-cigarettes or heat-not-burn technology – that is the information we have currently.  

Clearly these products have been designed and commercialised for the adult current smokers that intend to continue to smoke. The WHO has outlined that there will be 1 billion smokers by 2025, that 1 billion smokers who will continue to use nicotine, [should then] use alternative products.

Coenraad Bezuidenhout: Prof Malan I want to come to you. Do you think the regulatory authorities or other stakeholders have a responsibility to provide smokers with confidence in the claims that some of these manufacturers make? Or is it up to the manufacturers by themselves to do that?

Prof Malan: I think that you need information that’s available that is created in a scientific environment, that is trustworthy, that has been verified to be put out in the market, and to some extent to popularise it.

In other words, to say, here is the information that has been scientifically accredited. e-cigarettes for example have been called a “game changer” for public health by some respected physicians in the UK.

So that information should be published, it should be made available and I think consumers ultimately have the right to get access to information and they should demand that. But we also know that smokers by themselves without access to the information – being in the position where they are addicted – trying to quit smoking but failing many times, are unlikely to rally by themselves and to start advocating for this change.  So I think that the moral responsibility rests with various stakeholder groups including government to ensure that regulation reflects the merits of what is available.

One thing, let me just add to that which I think adds to the complexity at the moment, within the age that we live in now, which has been described as the 4th industrial revolution, we know that things develop very very quickly. One of the emerging terms in the field of government is agile governance – the need to come up with regulation where things change very quickly. One example is driverless cars and another one is artificial intelligence. The development is so quick that if you take the normal 2 -3 years to come up with the new regulation, by the time the regulation is passed, the product is already something else.

Dr Letlape: I think we need a policy in South Africa to come up with a framework about dissemination of information and how the public will be informed. It will be better that it’s done by an independent structure to communicate this to the smokers under the current environment.

Prof Rataemane: I just need to emphasise the need to approach harm reduction in a very specific way. We have to have a template of what harm reduction means. In that we have to eliminate moralising about the lifestyle, for instance, the fact that people who are addicted to smoking are to blame for their problem. There must be a reason underlying smoking or the need for the regular use of nicotine. But I think we have to also include more considered effort to promote alternative methods of delivering nicotine. Accepting that whatever policy we develop, it will not 100% stop people from wanting to receive nicotine in whatever manner. But what we want to emphasise is the need to deliver it in a safer way,

Marcelo Nico: Absolutely, I think we have a unique opportunity now that these less harmful alternatives are now available in the market – to inform smokers that there are alternatives out there and that the regulatory framework will allow informing these smokers, and encouraging the switching from more harmful products into harmful products.

Coenraad Bezuidenhout: Professor Malan for your closing comments I heard some echoes there to almost a developmental approach to address the situation, not only in terms of moving people from combustibles to less harmful products, but also in terms of looking at what are the societal causes of people engaging in heavy smoking and other harmful substances. Do you think that kind of approach will be helpful and even broaden the range of stakeholders, would that unnecessarily complicate it or do you think it’s essential?

Prof Malan: No I think it’s important, I would say that given the opportunities that we have now with the new products on the market and the scientific evidence that is available about the impact, that there’s a need for overall transparency and accountability.

Not only from the industry, but from other stakeholders as well in terms of having the clear and open mind in terms of accessing the new product and understanding how to respond to them – not only in terms of regulation but also in terms of marketing and research etc.

World Health Organization, headquartered in Geneva, Switzerland.

I think the industry will not need to hear it again but there is trust deficit that needs to be addressed. We know that today and everyday 13 000 people die as a result of smoking cigarettes and therefore the industry has to understand that they have to try even harder and accept that.

But at the same time, we must move away from simply digging in our heels saying that nothing good can come out of this. We need a pragmatic approach; we need to understand that when we talk about harm reduction it’s not about prevention of harm, it is about making things better, which everybody should be committed to.

If we going to start bringing out those old positions again, then ultimately people who suffer will be the consumers of different products and if we really have their best interests at heart then, we should take this very very seriously.

Coenraad Bezuidenhout: Thank you so much for joining us.