People trust the state less than doctors, which is where smoking comes in
Bans don’t work and never have, which is why doctors need to be at the forefront of changing unhealthy bevaviour
A healthy recovery from Covid-19 in SA will require more effective and scientifically informed action from the government and doctors. Unfortunately, public trust in the former is less than robust. Our recent survey in July of more than 1,000 adult South Africans shows that respondents have substantially higher trust in doctors than in the national government.
About 40% of those surveyed expressed a lot of trust in doctors, but only 10% hold the government in the same regard. Furthermore, almost a quarter of respondents expressed strong distrust in the government. Only 2% felt similarly about doctors.
We have seen unhealthy behaviours increase during the pandemic, with anxiety and stress compounding this. At the same time, individuals express a desire to change these habits and are seeking guidance on how to do so. They want better health.
Our survey, conducted in July, asked people which behaviours would have the biggest impact on health. Results showed that about half of SA adults believe increased physical activity and decreased consumption of sugary/fatty foods are the most important ways to influence health, and about a quarter believe drinking less alcohol and quitting smoking are the most important.
These four risk factors are the key determinants of many cancers, most heart disease, diabetes and chronic lung disease. Together, they drive the epidemic of chronic diseases.
Still, abstract knowledge about healthy behaviour does not necessarily equate to action. Nor does intent to change ensure an individual will do so. Nowhere is this clearer than in the case of smoking. Our survey showed that 80% of daily smokers seek to smoke less, and 58% said the pandemic has increased their desire to quit.
Yet, the pandemic has not led to a major reduction in smoking — because smokers intending to quit are impeded by a number of factors, including weak insight into the best tactics, poor access to cessation aids, and deep confusion regarding the value of safer nicotine products that can ease the quitting process.
For example, our poll in April found that 70% of respondents incorrectly believed nicotine is a major cause of cancer. Doctors’ roles in addressing many of these factors is inadequate, despite decades of international experience that shows when doctors lead with clear policies and personal example, governments listen, and smokers follow.
SA’s ban has increased illicit trade and done little to curb consumption, failures that are now coming to light in the court challenge to the legislation
Smokers are affected by their mistrust of the government. The ban on legal sales of cigarettes in SA (as well as all tobacco harm-reduction options) was implemented when anxiety levels were high. Our poll indicated that 66% of smokers use nicotine and tobacco products as a means of coping with stress.
The government ban on combustible cigarettes and tobacco harm-reduction (THR) options (such as Snus, e-cigarettes and heated tobacco products) does little to boost trust among smokers or help them quit. It is therefore not surprising that smokers have a greater distrust in the government (33%) than non-users (20%).
The government ban is misguided in many respects. Prohibition fails because people who are dependent will go to extreme, often dangerous, lengths to continue using tobacco products. Criminals fill the gap with illicit products that deprive the government of desperately needed excise tax.
SA’s ban has increased illicit trade and done little to curb consumption, failures that are now coming to light in the court challenge to the legislation.
Empathy for peoples’ struggles during the pandemic has no place in prohibitionist policies. It is increasingly clear that the country erred in conflating the need to control the pandemic with the need to “control” nicotine and alcohol use.
Moving forward, doctors should build on the trust people place in them, take the lead in educating the public about THR alternatives, and do more to improve their access to the approach they choose. In doing so, doctors must be armed with recent US Federal Drug Administration decisions that Snus and IQOS reduce exposure to many of the dangers of combustible cigarettes; the UK government reasons for its support of THR to help smokers quit; and the desire of millions of tobacco users worldwide for products that substantially reduce their risks relative to cigarettes.
The government could take far more decisive action to support smokers trying to quit. A bold way to start is to end the ban and commit to phase out sales of all combustible cigarettes over the next decade while supporting smokers to switch to the full range of THR, pharmaceutical and other means of quitting or complete cessation.
Trust in doctors and the government matters for complex behaviours driving chronic diseases, and this is urgent as we tackle the Covid-19 pandemic. Findings from our survey indicate that 31% of SA adults would not currently accept a Covid-19 vaccine. This figure is worrying and on the high side compared to other countries surveyed (8% in China, 16% in the UK, and 23% in Italy would not use the vaccine). Those who would use a vaccine have greater trust in the government and a substantially higher trust in doctors.
SA doctors play a crucial role in guiding healthy public policy. In the context of the pandemic they must do more to communicate the importance of vaccines and healthy behaviours that promote public health.
The government needs to support their policies and shift away from prohibitionist policies to more empathetic and science-based policies. This will engender the trust people need in the government to be certain it seeks what people seek — healthier futures.
• Yach is president of the Foundation for a Smoke-Free World. An SA-trained medical doctor living in the US, he is a former World Health Organisation cabinet director, and executive director for non-communicable diseases and mental health. He also worked at the SA Medical Research Council, was chief health officer of the Vitality Group, and has authored or co-authored more than 250 peer-reviewed articles on global health, as well as served on several advisory boards, including that of the World Economic Forum.
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