The overall socio-economic impact is equally concerning.  Annually around 6% of global health budgets are allocated to the treatment of smoking-related diseases, like lung cancer, chronic obstructive pulmonary disease (COPD), heart disease, and tuberculosis.

For various complex reasons LMICs have disproportionately high smoking prevalence rates. South Africa, with a prevalence of 31.4% (47% among men), is home to nearly 12 million of the world’s 1.14 billion tobacco users.

A new report prepared by The International Commission to Reignite the Fight Against Smoking urges physicians and HCWs to champion the most pressing public health cause of our time, a fight which has stalled over recent decades, and been displaced in the public eye by the COVID-19 pandemic. (See footnote).

Dr Kgosi Letlape, past President of the Health Professions Council of South Africa and South Africa’s Report Commissioner, says that the study calls for a more nuanced, holistic discussion around smoking, and an acknowledgement of the many recent innovations in Tobacco Harm Reduction (THR) technology.

He explains that, in part because of outdated curricula in medical, dental, and nursing schools, a “smoking kills. Quit-or-die!” narrative, which largely ignores these novel therapies and devices, has prevailed among Physicians.

“In the previous century, Physicians were our flag bearers, leading the charge against tobacco-use, and setting an example by quitting in droves themselves. Especially after the 1962 Royal College of Physicians report that, for the first time, definitively linked cancer to combustible tobacco”, Letlape says.

“This ushered in an era of ‘coercive permissiveness’ in healthcare, during which Physicians began to routinely offer unsolicited holistic lifestyle advice to patients. As the second-most trusted grouping of professionals in the world - more so even than state governments, civil society bodies or NGOs, and outranked only by scientists - Physicians have enormous influence and should reclaim their place as the natural leaders of international cessation efforts”.

But the challenges in bringing Physicians to the fore are numerous and complex. The report finds that even among Physicians, misinformation is rife. “Many HCWs still lack knowledge around THR, and falsely believe that ‘cold turkey’ quitting, which many smokers find impossible, is the only available option,” Letlape notes.

A key finding is that globally, an overwhelming majority of HCWs erroneously believe the nicotine in cigarettes is carcinogenic and is as dangerous as other extremely toxic cigarette ingredients. Furthermore, most respondents had never received training in tobacco cessation services.

“The science so far indicates that e-cigarettes and vaporisers are far less harmful than their combustible counterparts. But these alternatives are not completely harm-free, and Physicians in LMICs like SA may be reluctant to advise their use. This is well-intentioned, but misguided: Just like vaccines and other medical technologies, THR technologies are not completely risk-free, but nevertheless their potential benefits far outweigh the possible harms”, comments Letlape.

In LMICs where 80% of the world’s smokers reside, there are dire shortages of HCWs in many regions. Physicians are severely overworked and under immense psychological pressure. In Africa, 29% of Physicians are smokers themselves.

“With the burdens of many other pressing diseases to deal with, South African doctors simply do not have the time to adequately address smoking or educate themselves on the latest advancements in the THR field. Nor are they being compensated specifically to do so”, says Letlape.

“The lack of knowledge unearthed  by our surveys underscores an urgent need for medical practitioners in LMICs like SA to rise to the challenge, update their knowledge, and develop their practice to encompass provision of sound guidance to patients seeking to quit combustible smoking”, he notes.

Letlape asserts that, for many patients, encouraging them to quit smoking, or switch to a less harmful method of nicotine-delivery, is the best way a physician can improve their overall wellness. Supporting these patients will however take significant time and effort on the part of Physicians.

Besides efforts to address the systemic shortage of Physicians, and improve the ratio of HCWs in the population, Sub-Saharan Africa’s already over-burdened Physicians should also be adequately compensated for the time they spent on smoking cessation efforts, and fully supported by government in these endeavours. Ultimately this is a valid use of their time, as it would result in better health outcomes overall, and alleviate pressure on Africa’s public health systems”.

Letlape says that targeted support for Physicians could empower them to bring harm reduction solutions to their patients, especially within marginalised groups whose smoking prevalence rates are disproportionately high, and where necessary, to help them quit themselves.

“This support may come in the form of easy-to-access, knowledge and information campaigns, with instruction updated every few years to keep abreast of the latest developments, innovations, and refinements to best practice. Key aspects of this knowledge include the emerging science and technology (and the health effects thereof); consumers’ ever-evolving perceptions; and industry trends, including new products and alternatives to traditional smoking”, he says.

Letlape endorses the National Cancer Institute’s “Five A’s Approach” for medical professionals: Ask about tobacco use, Advise quitting, Assess a willingness to quit, Assist in the attempt to do so, and Arrange follow-up meetings.

“Mental health workers - whose patients’ smoking rate is up to 4 times higher than that of the general population - are also well poised to bring about high-impact positive change, by joining the fray and assisting those with mental health conditions to reduce their health risk through THR technologies or to quit altogether. Medical research professionals should also prioritise effective cessation strategies for high-risk patients who smoke, including those with mental health conditions, tuberculosis, heart disease and early-stage chronic lung disease”, says Letlape.

AI and big data may also play a pivotal role in SA’s future, with applications in ascertaining the knowledge, views and behaviours of Physicians, and utilising these insights to develop evidence-based solutions tailored to unique cultural and socio-economic contexts.

“Physicians now have the most powerful tool in history to combat smoking - technology that delivers nicotine without the massive health-risks associated with tobacco combustion. With this at their disposal, they can once again take their place at the helm of international cessation efforts, and continue to save lives, as they did in earnest over 60 years ago. Medical institutions, like the Royal College of Physicians and the World Medical Association, must re-establish themselves as leaders in the fight to end smoking in LMICs.  But as doctors we must put our patients first and practice what we preach, and quit smoking ourselves, or switch to the new, safer alternatives”, he concludes.