Sustaining success Submission on Bill B242006 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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NCAS mission

• To promote health and reduce the death and
  disease caused by the use of tobacco products

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Unique treatment for a unique product

• Tobacco is a uniquely dangerous consumer product.
  It is the only legal product that kills the user
  when used exactly as intended by the
  manufacturer.

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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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Smoking-Caused Diseases
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Smoking causes spontaneous abortion
Smoking during pregnancy poses special risks to
the developing foetus and is an important cause
of low birthweight and infant mortality. US
Surgeon Generals Report, 1989
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Lung cancer has overtaken breast cancer as a
cause of death in several countries
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Trends in SA

• The number of smokers dropped from 8.3 million in
  1993 to 5 million in 2005.
• There are 3 million fewer smokers.
• Between a 1/4 to 1/2 of these people would have
  died from a disease caused by smoking.
• Parliament has saved over a million South
  Africans from early deaths due to cancer, heart
  attacks and lung diseases

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Policy Makers Concerns about Controlling Tobacco
Use

• Job losses
• Loss of excise tax revenues
• Increased smuggling

World Bank, 1999
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• Tobacco control policies will not harm the
  economy or cause job losses.
• The World Bank, 1999

SAA
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Taxes

• Smokers pay taxes.
• Tobacco companies collect money from smokers and
  pass it on to the government. They are simply tax
  collectors.

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Smuggling

• What drives smuggling? High taxes or the tobacco
  industry?
• The difference in duty levels between
  neighbouring states is a MINOR cause of
  smuggling.
• Smuggling, is driven by the commercial activities
  of the tobacco companies

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Industry participation in smuggling

• The International Consortium of Investigative
  Journalists found
• British American Tobacco had for decades
  secretly encouraged tax evasion and cigarette
  smuggling in a global effort to secure market
  share and lure generations of new smokers.

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• In Industry sued
• Canada, Ecuador, the European Community filed
  lawsuits against international tobacco companies
  for smuggling.
• Philip Morris settled the EU lawsuit for 1.25
  billion.

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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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Section 2 Control over smoking of tobacco
products

• Aims
• To protect children from passive smoking
• To guarantee the constitutional right to an
  environment that is not harmful to health

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Background

• Cigarette smoke contains over 4500 chemicals,
  including over 200 known poisons (arsenic,
  cadmium, cyanide, nicotine, etc) and 60 chemicals
  that cause cancer.
• In some outdoor areas levels of tobacco smoke can
  be as high as in indoor areas.

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• 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 (brobnchitis 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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• Advantages of a total ban on smoking in indoor
  public places
• More effective than a partial ban in reducing
  pollution
• Fairer. Currently, those who work in smoking
  areas are still exposed to harm and
• Simpler, more consistent and easier to enforce.

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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)
  have welcomed 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

• Smoking near entrances to buildings is a problem.
  Smoke can drift into indoor areas though open
  doors, windows and ventilation inlets. People
  entering and exiting the building are also
  exposed to this pollution.
• In coffee shops and restaurants indoor diners are
  exposed to smoke from those smoking outside.
• The problem can be fairly easily solved by
  prohibiting smoking within 3 metres of any
  non-domestic building.
• Signs at entrances and moving ashtrays away from
  doorways help make the policy work.

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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 because they breathe more air
  relative to body weight than adults and so absorb
  more tobacco smoke toxins.
• 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.
• Vulnerable people, who are very sensitive to
  smoke, can have their health put at risk.

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Protecting the constitutional rights of workers

• The Constitution guarantees everyone the right
  to an environment that is not harmful to their
  health or well-being.
• Employers must respect employees rights to a
  clean environment and protect them from the harms
  caused by tobacco smoke pollution.
• Most people do not want to be exposed to tobacco
  smoke, but suffer in silence at work because they
  fear upsetting their employers.

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• They instead phone local authorities, the health
  department and non-governmental organizations
  seeking help while wishing to remain anonymous.
• The Bill proposes making it possible for people
  to voice their concerns without fear of
  repercussions.
• The Bill also places an obligation on employers
  to 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.
• Business owners cannot contract with their
  workers to relax workplace safety standards.

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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 the discriminatory situation
  where domestic workers are given less protection
  than other workers.
• Domestic workers health must be protected from
  pollution by tobacco smoke.

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Smoking in cars with child passengers

• There is strong public support for a ban on
  smoking in cars while children are passengers.
• Smoking in cars can produce high concentrations
  of smoke, especially if windows are closed
• A case can be made for banning smoking in any
  vehicle while driving like not using cell
  phones.
• Please prohibit smoking in cars while children
  are present. Public support for the ban is
  sufficient to ensure that enforcement will not be
  a problem.

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

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Policy goals

• To require tobacco manufacturers to produce the
  least harmful product technically possible by
  regulating
• the substances that the manufacturers can put
  into tobacco products (its constituents)
• the chemicals that may be produced when
  tobacco products are used (its emissions) and
• the physical design of tobacco products.

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Background

• Despite their toxicity, tobacco products are
  currently subject to little regulation regarding
  their content, design and manufacture.
• New tobacco products can be introduced and the
  design of currently available products can be
  changed with almost no regulatory oversight.

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• Paradoxically, 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 medicine and can only be sold through
  pharmacies.
• Not regulating nicotine in its deadliest form
  (cigarettes), while strictly regulating it in its
  safest form (medications) is not rational.

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• The cigarette is more than just dried tobacco
  wrapped in paper, and snuff is not simply
  powdered tobacco leaf.
• Enormous research has been done on the design and
  manufacture of tobacco products.
• The key goal is to deliver nicotine rapidly and
  in sufficient quantities to feed a smokers
  craving.

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Neurotransmitters Released by Nicotine in the
Brain
Benowitz, 1999
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The Manufactured Cigarette
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Cigarettes

• Designed to
• Maximize addiction,
• facilitate initiation and
• undermine cessation.

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• Ventilated filters provide cooler and more dilute
  smoke. Larger quantities of smoke can be more
  deeply inhaled into the lungs.
• Chemical are added to the tobacco, filter, and/or
  paper during the manufacture of cigarettes or
  snuff. These additives serve many purposes.

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Additives

• Up to 1400 chemicals can be added to tobacco.
  These
• Mask the irritating taste of smoke.
• Increase nicotine delivery.
• Keep the product fresh (anti-fungal).
• Control the rate at which cigarettes burn
  (nitrates).
• Produce a white ash (chalk).
• Give brands their special flavour (cocoa,
  chocolate).

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Additives

• There are no legal restrictions on what may be
  added to tobacco products
• Only the tobacco manufacturers know the additives
  used in each brand

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

• Chocolate, licorice, honey, sugars, menthol, and
  other flavourings help hide the unpleasant taste
  of tobacco.
• Menthol numbs the throat and reduces coughing.
• In October, 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,
  and so is deliberately increasing harm to the
  public.

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Emissions

• A lit cigarette produces over 4500 chemicals in
  the smoke.
• About half are found naturally in the tobacco
  leaf and half are created by chemical reactions
  when tobacco is burned.

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What does smoke contain?

• Irritants and Toxicants
• Ammonia
• Formaldehyde
• Carbon monoxide
• Nicotine
• Toluene
• Nitrogen dioxide
• Hydrogen cyanide
• Acrolein
• Acetaldehyde

• Carcinogens
• Benzoapyrene
• 2-Napthylamine
• 4- Aminobiphenyl
• Benzene
• Vinyl chloride
• Arsenic
• Chromium
• Polonium-210

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Regulatory Approach

• While it is impossible to make a cigarette safe,
  it is reasonable to prevent manufacturers doing
  anything that increases the harm caused by
  tobacco smoke.

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Regulatory Approach

• The Bill should
• Require manufacturers to disclose all additives
  used in tobacco products, by brand, to the
  government.
• Also require them to disclose the purpose of an
  additive and its biological effects, if any, when
  inhaled
• Enable government to order the removal of
  additives which increase harm.
• Only allow new additives if its safety can be
  demonstrated
• Permit additives necessary for the manufacturing
  and storage of tobacco products provided these
  are safe, but bar all additives that may
  influence smoking behavior.

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• The WHO FCTCs is developing guidelines for
  product regulation and testing.
• The Bill proposes providing legal authority to
  the Minister to develop standards for
  constituents, emissions, product design, and
  testing methods, once there are clear
  international guidelines for doing so.

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Reducing the fire-risks from cigarettes

• Policy goal
• To reduce deaths, injuries and property damages
  resulting from fires started by manufactured
  cigarettes.
• Background
• Cigarettes are a major cause of fires.
• 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, smoking
  while under the influence of alcohol, or the
  tossing away of a lit cigarette, can all start
  fires.

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• It is possible to reduce the likelihood that a
  lit cigarette will start a fire by altering its
  design.
• So cigarettes, if not puffed upon for a while,
  will 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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Conclusion

• The Bill will protect
• children
• workers and
• smokers.
• It is fair, reasonable and workable.

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Thank you
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Particle Size Determinant of Tar Nicotine Lung
Penetration
Too Large
.5 - 2 microns
Too Small
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Philip Morris (1950s)

• Insofar as particle size is a determinant of
  lung absorption of smoke, we should explore this
  as a way to reduce lung exposure to smoke (e.g.,
  1957, idea no. 99)
• History shows they did the opposite to
  increase efficiency of nicotine absorption as the
  priority concern over potentially increased lung
  cancer