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.

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.

"Are they trying to control us people?": News media coverage of COVID-19 lockdown tobacco sales ban in South Africa.

The South African government imposed one of the strictest lockdowns in the world as part of measures to curb the spread of COVID-19 in the country, including a ban on the sale of tobacco products. This study explored news media coverage of arguments and activities in relation to the South African lockdown tobacco sales ban. We collected media articles published between 26 March to 17 August 2020, which corresponded to the period of the sales ban. Data were sourced via google search and snowball identification of relevant articles. Thematic analysis of data was conducted with the aid of NVivo. We analysed a total of 305 articles relevant to the South African tobacco sales ban during the lockdown. Six major themes were identified in the data: challenges associated with implementing the ban, litigation, and threats of litigation to remove the ban, governance process and politicization of the ban, pro and anti-tobacco sales ban activities and arguments and reactions to the announcement lifting the ban. The initial reason for placing the ban was due to the non-classification of tobacco products as an essential item. Early findings of a link between tobacco smoking and COVID-19 disease severity led to an extension of the ban to protect South Africa's fragile health system. Pro-sales ban arguments included the importance of protecting the health system from collapse due to rising COVID-19 hospitalization, benefit of cessation, and the need for non-smokers to be protected from exposure to secondhand smoke. Anti-sales ban arguments included the adverse effect of nicotine withdrawal symptoms on smokers, loss of jobs and the expansion of the illicit cigarette markets. Litigation against the ban's legality was a strategy used by the tobacco industry to mobilize the public against the ban while promoting their business through the distribution of branded masks and door-to-door delivery which goes against current tobacco regulations. The media could serve as a veritable tool to promote public health if engaged in productive ways to communicate and promote public health regulations to the general population. Engagement with the media should be enhanced as part of health promotion strategies.

A cross-sectional investigation of softening indicators among South African smokers: Results from the South African Social Attitudes Survey between 2007 and 2018.

Recent studies have shown softening among smokers in different countries and in different population groups i.e., as smoking prevalence declined remaining smokers made more quit attempts and smoked fewer cigarettes per day (CPD), as opposed to hardening. We examined tobacco use-related cross-sectional data from five waves of the South African Social Attitudes Survey (SASAS 2007-2018, N = 14,822). Accounting for the SASAS's complex survey design, we ran logistic and linear regressions for smoking prevalence, and for the following indicators of softening: plans to quit smoking within a month, time to first cigarette (5 min, TTFC) and cigarettes smoked per day (CPD). We controlled for survey wave, age, sex, race, marital status, educational level and urban/rural residence. Smoking prevalence remained stable from 2007 (20.7%) to 2018 (22.2%) in the overall population of smokers (p = 0.197), and within sex and race group of smokers. In the adjusted model, there was a significant decline in CPD over time, 0.12 cigarettes per year. There was also a significant decrease in TTFC among males over time. Among women, CPD declined significantly by 0.32 cigarettes per year. The proportion of Asians/Indians planning to quit also decreased over time. South African smokers do not consistently show significant change in the softening indicators overall. Stronger tobacco control policies and better-tailored smoking cessation interventions are needed to achieve a significant decrease in smoking prevalence across sex and other subpopulations in 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.

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.

E-cigarette advertising exposure among South African adults in 2017: findings from a nationally representative cross-sectional survey.

OBJECTIVES: In South Africa, the Control of Tobacco and Electronic Delivery Systems Bill seeks to regulate e-cigarettes as tobacco products, including their advertising, promotion and sponsorship. Population data on e-cigarette advertising in South Africa are needed to inform public health programs, practice and policy. We examined self-reported e-cigarette advertising exposure during 2017. DESIGN: Cross-sectional. SETTING: Household-based survey. PARTICIPANTS: 3063 individuals who participated in the 2017 South African Social Attitudes survey, a nationally representative, in-person survey of the non-institutionalised civilian adult population aged ≥16 years EXPOSURE: 'In the past 12 months, have you seen advertisements or promotions for e-cigarettes (including e-shisha, e-pipe) on any of the following media: newspapers/magazines, billboards, in the malls or any other source?' MAIN OUTCOMES: Beliefs and attitudes regarding e-cigarettes. FINDINGS: Participants' mean age was 37.7 years. Overall, 20.1% reported exposure to e-cigarette advertisements. By age, exposure was most prevalent among those aged 16-19 years (24.6%). Top sources of exposure among those exposed were stores, 40.7%; malls, 30.9%; and television, 32.5%. Of those aware of e-cigarettes, 61.2% believed 'e-cigarette advertisements and promotion may make adolescents think of smoking traditional cigarettes'; 62.7% believed that 'e-cigarette advertisements and promotions may make ex-smokers think of starting smoking cigarettes again'; and 59.5% supported the statement that 'e-cigarette smoking should be banned indoors just as traditional cigarette smoking'. Notably, teens aged 16-19 reported the lowest prevalence (49.0%) of those believing that 'e-cigarette advertisements and promotion may make adolescents think of smoking traditional cigarettes', whereas this percentage was highest among those aged 55-64 years (73.2%). CONCLUSION: Comprehensive regulatory efforts are needed to address e-cigarette advertising, marketing and sponsorship in order to protect public health. The urgent enactment of the new tobacco control legislation, The Control of Tobacco Products and Electronic Delivery Systems Bill, can help reduce youth exposure to e-cigarette advertising in South Africa.

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.

Potential revenue from taxing e-cigarettes and comparison of annual costs of daily e-cigarette use versus daily cigarette smoking among South African adults.

INTRODUCTION: To inform policy making under the proposed The Control of Tobacco and Electronic Delivery Systems Bill, we compared annual costs of using e-cigarettes versus cigarettes, and estimated revenue from e-cigarette taxation. METHODS: We extracted e-cigarette retail prices from 231 South African e-cigarette vendor websites. We compared annual costs associated with daily cigarette smoking (self-reports from daily smokers in the 2018 South African Social Attitudes Survey, SASAS) versus daily e-cigarette use (based on cumulative costs of consumables plus device costs). We estimated revenue from excise tax if e-cigarettes were taxed at 75% (the rate proposed by the government) and 37.5% (half of the government's proposal as a hypothetical scenario) of the cigarette excise rate. We applied the different rates to e-cigarette consumption in 2018 SASAS and projected for 2021. RESULTS: Mean annual cost associated with daily use was ZAR 6693 (US$460.32, based on an exchange rate of about 69 US$ to 1000 ZAR) for manufactured cigarettes; for e-cigarettes, this ranged from ZAR 8574.69/year (with price minimizing strategies) to ZAR 19780.83/year (retail products exclusively). Expected revenue from e-cigarette excise tax at 75% of the cigarette tax rate was up to ZAR 2.20 billion (95% CI: 0.96-3.44). If taxed at 37.5% of the cigarette tax rate - half of the government's proposed rate - the projected revenue was up to ZAR 1.10 billion (95% CI: 0.48-1.72). Of the projected revenue from e-cigarette excise tax at 75% of the cigarette rate, the portion attributable to hardware (device and batteries) was 61% (ZAR 1.35 billion), while the portion attributable to e-liquid was 39% (ZAR 0.86 billion). CONCLUSIONS: Calculated daily costs were higher for e-cigarettes than cigarettes. We recommend an e-cigarette excise tax. The government's proposed tax rate may reduce youth e-cigarette access, while allowing adult smokers wishing to switch exclusively to e-cigarettes to reduce their tobacco-related harm.

Geospatial spread of e-cigarette vape shops in South Africa and the relationship with tobacco product use among adults.

We estimated the spatial distribution of e-cigarette vape shops in South Africa and measured associations with tobacco use among adults. We linked geocoordinates of identified vape shops to internet protocol addresses of individual participants in the 2018 Health 24 survey (n = 18,208). We used logistic regression to measure the associations between proximity to vape shops and tobacco-related behaviors. In total, we identified 240 vape shops; 49.6% of these were within a 5 km radius of a higher educational institution. Proximity to vape shops was associated with ever e-cigarette use among young adults aged 18-29 years (AOR = 1.33, 95%CI = 1.16-1.54). Efforts to regulate e-cigarette marketing can benefit public health.

On- and off-licensed premises drinking behaviour among adults in the city of Tshwane, South Africa: An analysis of data from the International Alcohol Control study.

INTRODUCTION AND AIMS: Alcohol use is among the leading risk factors for premature death and morbidity in South Africa. This study sought to identify factors associated with drinking behaviour in on- and off-licensed premises (typical occasion quantity and frequency) among adults in the City of Tshwane, South Africa. DESIGN AND METHODS: A household survey was conducted in 2014, using a multi-stage stratified cluster random sampling design. Participants comprised 982 adults (65% males) aged 18-65 years. Factors explored included socio-demographic variables and situational variables at on- and off-licensed premises. Multiple logistic regression analysis was performed to predict drinking behaviour at on- and off-licensed premises. RESULTS: The majority of the participants consumed alcohol in off-licensed premises (64% vs. 36%). However, participants who consumed alcohol at on-licensed premises were more likely to drink more alcohol and more frequently (weekly). Additionally, participants who consumed alcohol in above-average sized containers were more likely to consume six or more drinks and drink weekly. Being of high socio-economic status was associated with drinking weekly at off-licensed premises, while being less educated was associated with a significantly higher frequency of drinking at on-licensed premises. DISCUSSION AND CONCLUSIONS: Interventions to reduce alcohol use should target specific drinking behaviour at on- and off-licensed premises, for example, regulating the availability of alcohol in big-sized containers and the need for cutting down on quantity of alcohol and frequency of drinking for South African males who drink at on- and off-licensed premises.

Non-Smoker's Exposure to Second-Hand Smoke in South Africa during 2017.

Current South African tobacco control law allows for 25% designated smoking areas in some indoor public places. This study investigates non-smokers' exposure to second-hand smoke (SHS) in workplaces, homes, cafés/restaurants, and shebeens (local bars) using data from the 2017 South African Social Attitude Survey. Factors associated with any level of exposure were explored using multiple-variable-adjusted logistic regression analysis. The sample of 3063 participants (16+ years old), comprised 51.7% females and 78.5% Black Africans. The current smoking prevalence from this study was 21.5%. About 47% of non-smokers reported exposure to SHS in at least one location. Females were significantly less likely to be exposed to SHS in all locations except at home compared to males. Adjusted logistic regression analysis showed that females, adults aged 45-54 years, 55-64 years, and 65+ years were significantly less likely to be exposed to SHS (adjusted odds ratio (AOR) = 0.63, 0.60, 0.55, and 0.24, respectively) than males and those aged 16-24 years. Those who identified as Coloureds were significantly more likely to be exposed to SHS (AOR = 1.69) than Black Africans. This study found that nearly half of non-smokers reported exposure to SHS. A 100% smoke-free policy consistent with the World Health Organisation (WHO) Framework Convention on Tobacco Control would protect more people from exposure to SHS in South Africa.