Framing the policy debate over tobacco control legislation and tobacco taxation in South Africa.

BACKGROUND: In 2018, South Africa opened public consultations on its newly proposed tobacco control bill, resulting in substantial public debate in which a range of arguments, either in favour of or against the Bill, was advanced. These were accompanied by the recurring discussions about the annual adjustments in tobacco taxation. This study uses the concept of framing to examine the public debate in South African print media on the potential effects of the legislation, as well as tobacco tax regulations, between their proponents and detractors. METHODS: A systematic search of news articles using multiple data sources identified 132 media articles published between January 2018 and September 2019 that met the inclusion criteria. RESULTS: Seven overarching frames were identified as characterising the media debate, with the three dominant frames being Economic, Harm reduction and vaping, and Health. The leading Economic frame consisted primarily of arguments unsupportive of tobacco control legislation. Economic arguments were promoted by tobacco industry spokespeople, trade unions, organisations of retailers, media celebrities and think tanks-several of which have been identified as front groups or third-party lobbyists for the tobacco industry. CONCLUSION: The dominance of economic arguments opposing tobacco control legislation risks undermining tobacco control progress. Local and global tobacco control advocates should seek to build relationships with media, as well as collate and disseminate effective counterarguments to those advanced by the industry.

Associations between electronic cigarette use and quitting behaviours among South African adult smokers.

BACKGROUND: The South African Medicines Control Council classifies e-cigarettes as Schedule 3 substances and requires them to be dispensed only within pharmacies. e-Cigarettes are however ubiquitous and are marketed as cessation aids. We investigated the relationship between e-cigarette use and smoking cessation among South African adult smokers. METHODS: Data came from a 2018 web survey of South African adults aged ≥18 years (n=18 208). Cessation-related attitudes and behaviours were assessed. Using multivariable logistic regression, we measured the association between e-cigarette use and cessation behaviours among ever-established combustible tobacco smokers who tried to quit. FINDINGS: Among current combustible smokers, more e-cigarette ever versus never users believed e-cigarettes could assist smokers to completely quit (35.5% vs 20.4%) or cut down (51.7% vs 26.5%) (all p<0.05). Among ever-established smokers, the odds of sustained quitting at the 12-month mark were lower among those who used e-cigarettes once off/rarely (adjusted OR (AOR)=0.20, 95% CI=0.16-0.24), former e-cigarette users (AOR=0.30, 95% CI=0.24-0.38) and current e-cigarette users (AOR=0.23, 95% CI=0.18-0.29), compared with never e-cigarette users. Among ever-established smokers who had ever tried to quit, 53.6% relapsed into smoking after quitting for any length of time. The odds of relapsing among ever-established smokers who had made a quit attempt and had a quit intention were higher among those who used e-cigarettes once off/rarely (AOR=2.66; 95% CI=2.31-3.08), former e-cigarette users (AOR=1.41; 95% CI=1.18-1.69) and current e-cigarette users (AOR=1.85; 95% CI=1.55-2.22) than never e-cigarette users. CONCLUSION: e-Cigarette use depressed long-term cessation. These findings can inform restrictions on unsubstantiated claims of e-cigarettes as cessation aids within South Africa.

Landscape of tobacco control in sub-Saharan Africa.

Yearly, tobacco use kills about 8 million people globally, 80% of whom live in low/middle-income countries. Given sub-Saharan Africa's (SSA) rapidly increasing and youthful population, growing incomes and the increased presence of the tobacco industry, the number of tobacco users is growing. The region is predicted to face a heavier burden of tobacco-related diseases and deaths in the future. We examined the policy, advocacy, economic and media landscapes of tobacco control as well as tobacco industry interference in SSA. We also highlighted key challenges and priorities for intervention in the region. Their vast financial power has enabled transnational tobacco companies to interfere in tobacco control and slow down policy implementation efforts in SSA. Despite recent gains, inadequate investment in tobacco control has prevented effective tobacco control implementation in SSA. Other challenges include limited locally generated evidence and limited support from mainstream media to back policy and advocacy efforts. Finally, taxation, which is one of the most effective tools for tobacco control, is not yet adequately used in SSA partly due to non-harmonised taxation rates as well as exaggerated and false claims about the potential impacts of increasing taxes, especially that it will increase smuggling. Key priorities to address these challenges include continued strategic funding, capacity building of government and advocacy personnel to strengthen tobacco control governance, regional and institutional cooperation, harmonisation of subregional tax policies, cooperation among international funders, and increased industry monitoring and research in SSA.

Moving targets: how the rapidly changing tobacco and nicotine landscape creates advertising and promotion policy challenges.

Tobacco, nicotine and related products have and continue to change rapidly, creating new challenges for policies regulating their advertising, promotion, sponsorship and sales. This paper reviews recent commercial product offerings and the regulatory challenges associated with them. This includes electronic nicotine delivery systems, electronic non-nicotine delivery systems, personal vaporisers, heated tobacco products, nicotine salts, tobacco-free nicotine products, other nicotine products resembling nicotine replacement therapies, and various vitamin and cannabis products that share delivery devices or marketing channels with tobacco products. There is substantial variation in the availability of these tobacco, nicotine, vaporised, and related products globally, and policies regulating these products also vary substantially between countries. Many of these products avoid regulation by exploiting loopholes in the definition of tobacco or nicotine products, or by occupying a regulatory grey area where authority is unclear. These challenges will increase as the tobacco industry continues to diversify its product portfolio, and weaponises 'tobacco harm reduction' rhetoric to undermine policies limiting marketing, promotion and taxation of tobacco, nicotine and related products. Tobacco control policy often lags behind the evolution of the industry, which may continue to sell these products for years while regulations are established, refined or enforced. Policies that anticipate commercial tobacco, nicotine and related product and marketing changes and that are broad enough to cover these product developments are needed.

Circumvention of COVID-19-related restrictions on tobacco sales by the e-cigarette industry in South Africa and comparative analyses of heated tobacco product vs combustible cigarette volume sales during 2018-2020.

As a public health measure against COVID-19, South Africa restricted the sale of "tobacco, e-cigarettes and related products" for 5 months, ending on August 17, 2020. We examined marketing activities related to novel tobacco products (e-cigarettes and heated tobacco products) during this restriction. Using web scraping, we accessed data for 2661 e-cigarette liquids marketed online by South African vendors in June 2020. We also analyzed heated tobacco product volume sales (kits) using retail scanner data from Nielsen Company. The 2661 e-cigarette liquids assessed online comprised cannabidiol liquids, 28.8%[767/2661], nicotine salts, 10.4%[276/2661], e-cigarette juice concentrates, 14.1%[376/2661], nicotine-free e-liquid, 4.0%[107/2661], and nicotine-containing e-liquid, 42.6%[1135/2661]. Cannabidiol liquids had the highest percentage of fruit (78.4%[601/767]) and tobacco flavors (9.4%[72/767]). During the restriction, many online e-cigarette vendors actively promoted cannabidiol liquid in lieu of regular e-liquid. Nielsen retail scanner data showed that volume of heated tobacco product sales in February 2020, preceding the restriction (7.76 million kits), were higher than in February 2019 (4.52 million kits). The restriction saw decreased sales of heated tobacco products; mean weekly heated tobacco product sales in the 6 weeks following the restriction (772,585 kits/week) were dramatically lower versus the 6 weeks preceding the restriction (2.26 million kits/week). Lifting the restriction saw a 131% spike in sales between the latter half of August 2020 (825,638 kits) and mid-September 2020 sales (1.90 million kits), even though total sales in September 2020 were half of what was observed in the preceding year (3.81 million units in September 2020, vs 6.33 million units, September 2019). The marketing of cannabidiol and other novel products by e-cigarette manufacturers and the tobacco industry may encourage youth use; close monitoring is required.

Framework Convention on Tobacco Control Implementation in Nigeria: Lessons for Low- and Middle-Income Countries.

BACKGROUND: Nigeria is a significant tobacco market and influential country in Africa. Nigeria ratified the WHO Framework Convention on Tobacco Control (FCTC) in 2005. We reviewed Nigeria's tobacco control legislation since 2000 and compliance of the National Tobacco Control Act (NTCA) 2015 with the FCTC. METHODS: We reviewed the National Tobacco Control Bills 2011 (proposed by legislature) and 2014 (proposed by Executive), the NTCA 2015, and media stories on tobacco control from 2008 to 2017. RESULTS: The NTCA, despite being more comprehensive than Nigeria's first Tobacco Smoking (Control) law of 1990, maintained provisions promoted by the tobacco industry, for example: allowing designated smoking areas in hospitality venues, higher educational institutions, and transportation venues; a loophole in the advertising restrictions allowing communications with consenting adults; and having the Manufacturers Association of Nigeria (MAN) (which includes tobacco companies) on the National Tobacco Control Committee charged with working with the Ministry of Health to implement the law. The industry is also directly involved with the Standards Organisation of Nigeria (SON) in preparing regulations on cigarette constituents and emissions. In an unprecedented step globally, the law requires that implementing regulations be approved by the National Assembly, giving the industry another opportunity to weaken this law further by lobbying the legislators to favor the industry. As of January 2018, the law was still not being enforced. CONCLUSION: The NTCA can be strengthened through implementation guidelines still being developed. The industry should be prevented from interfering with through MAN and SON, as required by FCTC Article 5.3. IMPLICATIONS: The tobacco industry works to block Framework Convention on Tobacco Control implementation even after a country ratifies the treaty. The Nigerian case illustrates that it is essential for health authorities to remain vigilant and ensure that the tobacco industry does not play a decision-making role in the process of tobacco legislation and regulation either directly or indirectly. The unprecedented step of requiring approval of implementing regulations for the Nigerian law should not be allowed to become a precedent in other countries.

Role of stakeholders in Nigeria's tobacco control journey after the FCTC: lessons for tobacco control advocacy in low-income and middle-income countries.

INTRODUCTION: Nigeria ratified the WHO Framework Convention on Tobacco Control (FCTC) in 2005. Tobacco control advocates in Nigeria achieved some success in countering tobacco industry interference to implement the FCTC. METHODS: We triangulated interviews with key informants from local and international organisations who worked in Nigeria with documentation of the legislative process and Nigerian newspaper articles. Data were analysed and interpreted using the Policy Dystopia Model and WHO categories of tobacco industry interference that had been developed mostly based on experience in high-income countries. RESULTS: As in high-income countries, the tobacco industry continued to oppose tobacco control policies after Nigeria ratified the FCTC, including weakening Nigeria's 2015 National Tobacco Control Act. Both tobacco control advocates and industry used discursive (argument-based) and instrumental (activity-based) strategies. The industry argued self-regulation and the economic importance of tobacco. They exploited legislative procedures, used front groups and third parties to push for pro-industry changes. Advocates, with help from international organisations, mobilised prominent Nigerians and the public. Advocates pre-empted and countered the industry through traditional and social media, monitoring and exposing tobacco industry activities, and by actively engaging lawmakers and citizens during the legislative process. CONCLUSION: The Policy Dystopia Model and WHO categories of industry interference provide a helpful framework for understanding tobacco control debates in low/middle-income countries (LMICs) as in high-income countries. One difference in LMIC is the important role of international tobacco control advocates in supporting national tobacco control advocates. This partnership is important in pushing for FCTC-compliant legislation and countering industry activities in LMIC.

Tobacco use and nicotine dependence among people living with HIV who drink heavily in South Africa: a cross-sectional baseline study.

BACKGROUND: People living with HIV (PLWH) who drink alcohol and use tobacco are particularly vulnerable to tobacco-induced diseases due to an already compromised immune system. This study investigated the prevalence and factors associated with tobacco use (cigarette and snuff) among PLWH who drink heavily. METHODS: Participants (n = 623) on antiretroviral therapy for HIV who reported heavy drinking using the Alcohol Use Disorders Identification Test (AUDIT) and AUDIT-C were recruited from six hospitals in Gauteng Province, South Africa. The Fagerström test was used to assess nicotine dependence. Chi Square tests and modified Poisson regression analyses were conducted to identify factors associated with tobacco use. RESULTS: Almost half of the participants reported ever smoking (44.0%; CI: 40.1-47.9) and about a quarter reported ever using snuff (25.5%; CI: 22.2-29.1). Current smokers and current snuff users comprised 27.3% (CI: 23.9-30.9) and 19.1% (CI: 16.2-22.3) of all participants respectively. Among current smokers, 37.9% (CI: 30.8-45.3) were moderately/highly dependent on nicotine. Current 'any tobacco product users' (ATPU: use cigarettes or snuff) were 45.4% (CI: 41.5-49.3) while 1.0% (CI: 0.4-2.0) currently used cigarettes and snuff. Adjusted regression analyses showed that, compared to males, females were less at risk of being: ever smokers (Relative Risk Ratio [RRR] = 0.33; CI: 0.27-0.41), current smokers (RRR = 0.18; CI: 0.12-0.25), and ATPU (RRR = 0.75; CI: 0.63-0.89) but were more at risk of ever snuff use (RRR = 5.23; CI: 3.31-8.25), or current snuff use (RRR = 26.19; CI: 8.32-82.40) than males. Ever snuff users (RRR = 1.32; CI: 1.03-1.70), current snuff users (RRR = 1.40; CI: 1.03-1.89) and ATPU (RRR = 1.27; CI: 1.07-1.51) were more at risk of reporting significant depressive symptoms. We found no significant associations between smoking status and years on ART and viral load. CONCLUSION: There is a high prevalence of cigarette and snuff use among PLWH who drink heavily. Tobacco use cessation interventions tailored specifically for this population and according to their tobacco product of choice are urgently needed given their vulnerability to ill-health.

Avoiding "A Massive Spin-Off Effect in West Africa and Beyond": The Tobacco Industry Stymies Tobacco Control in Nigeria.

BACKGROUND: Nigeria plays important economic and political roles in Africa and is a significant market for the tobacco industry. This study describes the tobacco industry's efforts to block Nigeria's early tobacco control attempts, especially the Tobacco Smoking (Control) Decree 20 of 1990, and efforts to strengthen the Decree in 1995. METHOD: Analysis of documents from the Truth Tobacco Documents Library and other Internet resources related to Nigeria's Decree 20 and earlier tobacco control efforts. RESULTS: The World Conferences on Smoking and Health and World Health Organization in the late 1970s spurred the Nigerian government to take steps towards tobacco regulation. In response, the tobacco industry lobbied government ministries, used front groups and its trade group, the Tobacco Advisory Council of Nigeria, to block and weaken government efforts. The industry obtained a draft of Decree 20 two years before it was enacted, considered the Decree anti-business and proposed language that led to the passage of a weaker Decree in 1990. It also attempted to influence a potential review of the Decree in 1995. CONCLUSION: Decree 20 was a strong law for its time, but was weakened due to tobacco industry interference. Nigeria ratified the WHO Framework Convention on Tobacco Control (FCTC) in 2005, and enacted a comprehensive National Tobacco Control Act (NTCA) in May 2015. Lessons learned from Decree 20's experience should be applied to protect NTCA 2015, and in compliance with WHO FCTC Article 5.3 which require parties to protect tobacco control policies from tobacco industry interference. IMPLICATIONS: This is the first detailed account of tobacco industry interference with tobacco legislation in Africa. The emergence of tobacco control in Nigeria threatened the tobacco industry, which believed that success in Nigeria would have a "domino effect" in Africa. The industry used lobbying and front groups to successfully block and weaken Nigeria's tobacco control, especially the Tobacco Smoking (Control) Decree 20 of 1990 and efforts to strengthen it in 1995. Nigeria and other African countries must learn from this history to protect tobacco control policies from the tobacco industry's vested interests and vigorously implement Article 5.3 of the WHO FCTC.

Depression, suicidality, and alcohol use disorder among people living with HIV/AIDS in Nigeria.

BACKGROUND: People Living with HIV/AIDS (PLHIV) face various day-to-day and long-term personal, interpersonal, social, physical and psychological challenges as a result of, and in addition to the health conditions they are susceptible to due to their HIV status. There is a dearth of large-scale research to provide robust prevalence estimates of mental health problems among PLHIV, especially in Nigeria. This study aimed to ascertain the prevalence and factors associated with major depressive episodes, suicidality, and alcohol use disorder among people living with HIV/AIDS in Nigeria. METHODS: A survey of 1187 participants aged 18 years and above was conducted within three HIV treatment centres in Abuja, Nigeria. Depression, suicidality, and alcohol use disorder modules of the WHO World Mental Health Composite International Diagnostic Interview questionnaire were used for this study. A socio-demographic questionnaire was also used to collect other health and demographic data. Descriptive statistics (frequency distribution, percentage, mean, median, mode, and standard deviation) and regression analyses were conducted to explore associations between mental health problems and demographic and other health-related factors. RESULTS: Twelve-month prevalence rates were 28.2% for major depressive episodes, 2.9% for suicidal ideation, 2.3% for suicide attempts, 7.8% for harmful alcohol use, 7.0% for alcohol abuse, and 2.2% for alcohol dependence. Major depressive episodes were significantly associated with having planned suicide and marital status. Suicidal ideation was significantly associated with major depressive episodes, marital status, and religion. Females were less likely to be diagnosed with alcohol disorders. CONCLUSIONS: Some people living with HIV/AIDS also tend to suffer from depression, suicidality, and alcohol use disorders. These findings highlight the need for the integration of mental health services into HIV/AIDS care in Nigeria.

Systematic review of feasibility and acceptability of psychosocial interventions for schizophrenia in low and middle income countries.

BACKGROUND: In low and middle income countries there is evidence to suggest effectiveness of community-based psychosocial interventions for schizophrenia. Many psychosocial interventions have however been conceptualized in high income countries and assessing their feasibility and acceptability in low and middle income countries is pertinent and the objective of this review. METHODS: Six databases were searched using search terms (i) "Schizophrenia"; (ii) "Low and middle income or developing countries" and (iii) "Psychosocial interventions". Abstracts identified were extracted to an EndNote Database. Two authors independently reviewed abstracts according to defined inclusion and exclusion criteria. Full papers were accessed of studies meeting these criteria, or for which more information was needed to include or exclude them. Data were extracted from included studies using a predesigned data extraction form. Qualitative synthesis of qualitative and quantitative data was conducted. RESULTS: 14 037 abstracts were identified through searches. 196 full articles were reviewed with 17 articles meeting the inclusion criteria. Little data emerged on feasibility. Barriers to feasibility were noted including low education levels of participants, unavailability of caregivers, and logistical issues such as difficulty in follow up of participants. Evidence of acceptability was noted in high participation rates and levels of satisfaction with interventions. CONCLUSIONS: While there is preliminary evidence to suggest acceptability of community-based psychosocial interventions for schizophrenia in low and middle income countries, evidence for overall feasibility is currently lacking. Well-designed intervention studies incorporating specific measures of acceptability and feasibility are needed.

Barriers to accessing HIV services for Black African communities in Cambridgeshire, the United Kingdom.

The majority of new HIV diagnoses in the United Kingdom (UK) occur in people with heterosexually acquired HIV infection, the majority of whom are African communities. Current research shows that despite health promotion efforts and advances in therapy these communities are accessing HIV care late. This study therefore explored barriers to equal access to HIV services by African migrants in the UK. Kleinman's (Patients and healers in the context of culture: an exploration of the borderland between anthropology, medicine, and psychiatry, vol 3. University of California Press, Berkeley, 1980) model of health care systems was applied in this research as a theoretical framework and lens through which the reported findings are viewed as it places health within the broader context of culture. In this research a qualitative approach with focus groups was used. A total of thirty participants were recruited from African migrant community organisations in Cambridgeshire in the East of England strategic health authority in order to study the experiences of African migrants when accessing sexual health services. It was found that barriers to equal access to HIV services exist for African communities in Cambridgeshire. These included language barriers and others bordering on the use of traditional medicine by African migrants, understanding of cultural diversity, awareness of how and where to access HIV services, and getting information about HIV. Findings highlighted the importance of taking the sectors of Kleinman's [1] model into consideration when planning HIV services for African communities.

Psychiatric stigma and discrimination in South Africa: perspectives from key stakeholders.

BACKGROUND: Stigma and discrimination against people with mental illness remain barriers to help seeking and full recovery for people in need of mental health services. Yet there is scarce research investigating the experiences of psychiatric stigma on mental health service users in low- and middle-income countries (LMICs). The aim of this study was therefore to explore the experiences of psychiatric stigma by service users in order to inform interventions to reduce such stigma and discrimination in one LMIC, namely South Africa. METHODS: Participants comprised a total of 77 adults aged above 18 years, made up of service providers including professional nurses (10), lay counsellors (20), auxiliary social workers (2); and service users (45). RESULTS: Psychiatric stigma was found to be perpetuated by family members, friends, employers, community members and health care providers. Causes of psychiatric stigma identified included misconceptions about mental illness often leading to delays in help-seeking. Experiencing psychiatric stigma was reported to worsen the health of service users and impede their capacity to lead and recover a normal life. CONCLUSION: Media campaigns and interventions to reduce stigma should be designed to address specific stigmatizing behaviours among specific segments of the population. Counselling of families, caregivers and service users should include how to deal with experienced and internalized stigma.

An exploratory study of the socio-cultural risk influences for cigarette smoking among Southern Nigerian youth.

BACKGROUND: The increase in smoking prevalence in developing countries including Nigeria has been mainly blamed on the aggressive marketing strategies of big tobacco companies. There is a paucity of research on other socio-cultural risk factors for smoking among the youth. The main objective of this study is to explore and describe socio-cultural risk factors influencing cigarette smoking among the youth in Southern Nigeria. METHODS: A total of 27 respondents (5 community leaders, 4 political analysts and 18 young cigarette smokers) were interviewed using a semi-structured interview guide. Interpretative Phenomenological Analysis (IPA) was used to analyse the data. RESULTS: Social-cultural practices fuelling early usage and exposure of children to cigarettes and the promotional activities of tobacco companies were identified as possible factors influencing youth's smoking behaviour in Southern Nigeria. CONCLUSION: Tobacco control policies should include cultural interventions to modify current traditional practices and social norms which fuel the use of tobacco in the society. Such interventions must target specific groups, subpopulations and subcultures more exposed to the cultural risk influences for smoking.

Tobacco Vendors' Perceptions and Compliance with Tobacco Control Laws in Nigeria.

Tobacco vendors are critical stakeholders in the tobacco supply chain. This study examined their perception, compliance, and potential economic impact of Nigeria's tobacco control laws related to the retail setting. This was a qualitative study involving in-depth interviews of 24 purposively selected tobacco vendors. The face-to-face interviews were aided by a semi-structured interview guide, audio-recorded, transcribed verbatim, and analyzed using thematic analysis with NVivo version 12. Five themes emerged, encompassing reasons for selling tobacco, awareness, perception, compliance with tobacco sales laws, the potential economic impact of the laws, and law enforcement activities. Vendors commenced tobacco sales due to consumers' demand, profit motives, and advice from close family relatives. They were unaware and non-compliant with most of the retail-related laws. Most participants had positive perceptions about the ban on sales to and by minors, were indifferent about the ban on Tobacco Advertising Promotion and Sponsorships (TAPS) and product display, and had negative perceptions about the ban on sales of single sticks. Most vendors stated quitting tobacco sales would not have a serious economic impact on their business. In conclusion, the vendors demonstrated limited awareness and non-compliance with various retail-oriented tobacco control laws in Nigeria. Addressing these gaps requires targeted educational campaigns and effective law enforcement strategies to enhance vendors' compliance.

Trends in the use and dual use of factory-made combustible cigarettes, other tobacco products and electronic cigarettes: Results from South African Social Attitudes Surveys during 2007 to 2018.

INTRODUCTION: Using more than one tobacco product increases the risk of tobacco-related diseases. We investigated trends in the prevalence and dual use of factory-made (FM) cigarettes, other tobacco products, and electronic cigarettes (e-cigarettes) in South Africa over a 12-year period. METHODS: Data from five waves (2007, 2010, 2011, 2017, and 2018) of the South African Social Attitudes Survey (n=14582) were analyzed. The use of FM, roll-your-own (RYO) cigarettes, cigars, waterpipe, smokeless tobacco (SLT), any combustible tobacco products (CTP), any tobacco product (ATP) use, and e-cigarettes was investigated. The dual use of FM cigarettes with either SLT, waterpipe or e-cigarettes was also explored. Chi-squared analyses and regression models were used to explore trends in prevalence over the 12-year period. RESULTS: About 51% of the participants were female, and 51.9% were aged 16-34 years. CTP smoking significantly increased from 18.1% (2010) to 23.6% (2018) (p=0.015), while ATPU increased from 20.2% (2010) to 25.9% (2018) (p=0.005). Though dual use of FM cigarettes and SLT, waterpipe, or e-cigarettes was generally low, the prevalence of dual use significantly increased for all product combinations investigated: FM cigarettes and SLT (0.5% in 2007 to 1.3% in 2018, p=0.017), FM cigarettes and waterpipe (0.9% in 2010 to 2.5% in 2018, p=0.014), FM cigarettes and e-cigarettes (0.4% in 2010 to 1.8% in 2018, p<0.001). Compared to 2010, the odds of the prevalence of CTP and ATP use significantly increased by 37% in 2018 (adjusted odds ratio, AOR=1.37; 95% CI: 1.06-1.77; p=0.018 and AOR=1.37; 95% CI: 1.08-1.73; p=0.009, respectively) during the 12-year period after adjusting for demographic characteristics. CONCLUSIONS: The use and dual use of tobacco and electronic cigarette products have been increasing in recent years in South Africa. Interventions to help users quit and prevent young people from initiating use are urgently needed to curb these increases.