South Africa: SA Cannot End TB While Tobacco and Nicotine Addiction Go Unchecked

If South Africa is serious about ending TB, protecting people living with HIV, and safeguarding the next generation from nicotine addiction, Parliament must finally pass the Tobacco Products and Electronic Delivery Systems Control Bill, argues Professor Lekan Ayo-Yusuf, as we mark World No Tobacco Day on May 31.

South Africa has made enormous progress in helping people living with HIV survive and live longer lives. But with that success comes the new challenge of preventing and managing chronic diseases that continue to shorten lives unnecessarily. One of the biggest, and most overlooked, threats is tobacco and nicotine addiction.

This matters not only because smoking causes cancer, heart disease and stroke. Smoking also increases the risk of developing tuberculosis (TB), worsens treatment outcomes, and increases the risk of death from TB.

A seminal report from the World Health Organization and many other studies, including work involving South African researchers, have shown that tobacco smoke and nicotine weaken the immune responses needed to fight TB infection. Emerging evidence suggests that nicotine exposure from e-cigarettes and vaping products may have similar harmful effects on the body’s ability to respond to infections.

This is particularly worrying in South Africa, where TB and HIV remain deeply intertwined public health crises. In fact, a recent simulation study suggests that among virologically suppressed people with HIV in South Africa, tobacco smoking decreases life expectancy more than HIV.

SA sees a boom in nicotine products

Yet instead of urgent action to reduce nicotine addiction, South Africa has witnessed an explosion of vape shops, social media marketing, flavoured disposable vapes laced with high levels of highly addictive nicotine salt, and products designed to appeal directly to young people.

The tobacco and vaping industries insist these products are about “harm reduction”. But we have to question what kind of harm reduction strategies recruit teenagers who never smoked in the first place?

Over the past 15 years, few would dispute that South Africa has effectively become a natural experiment in unregulated nicotine product expansion. The results are alarming. Data from South African surveys show rising cigarette and hubbly smoking and rising vaping among young adults, with many people now smoking cigarettes and vaping rather than switching completely away from cigarettes.

There is a strong case to be made that this directly undermines the claim that these products are reducing harm at a population level.

Importantly, the Tobacco Products and Electronic Delivery Systems Control Bill, which was tabled in the National Assembly in December 2022, does not ban vaping products or other nicotine devices. What it proposes is regulation – the same kind of regulation already implemented in many countries, including in Kenya where the industry have voluntarily implemented graphic warnings on packages of vapes and oral nicotine pouches, while a bill is being considered.

The Bill before the South African Parliament would introduce measures such as stronger smoke-free laws to protect non-smokers, regulation of packaging, restrictions on advertising and promotion aimed at reducing youth exposure to nicotine marketing. These are effective public health measures informed by local evidence and our socioeconomic context, not extreme policies or a foreign agenda.

A case of smoke and mirrors

Yet public discussion around the Bill has increasingly been distorted.

Instead of focusing on health, some opposing the Bill – often allies of the industry – have reduced the debate to claims about illicit trade, job losses and threats to personal freedom. These distorted views were reflected in the seemingly industry-biased report presented as the summary matrix of the public submissions on the Bill. This is deeply concerning.

It is important to note that the illicit cigarette trade in South Africa did not begin with tobacco control laws or the temporary COVID-19 cigarette sales ban. Research shows illicit trade was already increasing long before COVID-19, largely because of weak enforcement, under-declaration of production, and failure to implement effective track-and-trace systems. Evidence suggests that most illicit cigarettes consumed in South Africa originate from local manufacturers themselves. In other words, illicit trade is fundamentally a law enforcement and governance problem, not a reason to weaken public health protections.

The industry has also weaponised poverty and unemployment to resist regulation, creating the impression that protecting public health will destroy livelihoods. But this ignores the enormous economic burden caused by smoking-related disease, lost productivity, and premature deaths. Smoking-related diseases already cost South Africa tens of billions of rand annually while contributing to more than 30 000 deaths in 2023 alone.

And there is another uncomfortable question South Africans should ask. If multinational tobacco companies comply with similar regulations in countries such as Uganda, the United Kingdom and elsewhere, why should South Africans deserve weaker protections?

Why are policies considered acceptable in other low- and middle-income countries like ours suddenly portrayed as unreasonable when proposed here?

The path ahead

South Africa stands at a critical crossroads. We can continue allowing industry interests to shape the conversation while nicotine addiction spreads among young people, or we can act decisively to protect future generations.

Passing the Tobacco Products and Electronic Delivery Systems Control Bill will not solve every public health challenge overnight. But it is one of the clearest and most urgently needed interventions available to reduce future burdens of TB, cancer, heart disease and nicotine addiction.

The delay has already gone on too long considering that the Bill was first published back in 2018.

If South Africa is serious about ending TB, protecting people living with HIV and safeguarding the next generation from addiction, Parliament must stop listening to industry noise and finally pass the Bill.

*Professor Ayo-Yusuf heads the School of Health Systems and Public Health at the University of Pretoria and is the Director of the Africa Centre for Tobacco Industry Monitoring and Policy Research.

By spotlight.