Sustaining success

Submission 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

Cancers

Lung

LarynxOesophagus

Bladder

Kidney and Ureter

Pancreas

Oral pharynx

Stroke

Coronary heart disease

Aortic aneurysm

Atherosclerotic peripheral vascular disease

Chronic obstructive pulmonary disease (COPD)

Chronic 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 General’s 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 Maker’s 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 employee’s 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 smoker’s 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 manufacturer’s 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 Medicine’s 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.

Neurotransmitters Released by Nicotine in the Brain

Benowitz, 1999

Dopamine

Noradrenaline

Acetylcholine

Vasopressin

Serotonin

Beta-endorphin

Pleasure, appetite suppressionArousal, appetite suppression

Arousal, cognitive enhancement

Memory improvement

Mood modulation, appetite suppression

Reduction of anxiety and tension

Nicotine

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The Manufactured Cigarette

Tobacco and additives

Tipping paper

Cigarette Paper Adhesive

Plugwrap Paper

FilterMonogram

Ink Cigarette paper

Ventilation holes

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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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QuickTime™ and aTIFF (LZW) decompressor

are needed to see this picture.

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What does smoke contain?

Irritants and Toxicants:

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

Carcinogens:

• Benzo[a]pyrene• 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 manufacturer’s 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 FCTC’s 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 Small

Too Large

.5 - 2 microns

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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