The colonial past and subsequent apartheid were glaringly reflected in economy and state of population health within South Africa. Post-apartheid public expectations and nationalist fervor compelled ANC government in 1994 to attach priority to health sector reforms in order to establish credibility and address prevailing inequalities in South African society. These injustices and economic disparities might also be motivating factors behind anti-tobacco efforts and advocacy campaigns which preceded abolition of apartheid. Throughout 20th century, tobacco smoking in South Africa contributed to colossal losses in the form of morbidity and mortality while the health system remained tilted in favor of certain privileged population groups. To complicate the situation further, appearance of HIV/AIDS and rise in burden of chronic diseases warranted urgent response.
New constitution clearly and correctly recognized healthcare as human right while declaring health of South Africans as a responsibility of state. This resulted from decades-long struggle of academia and health activists which relied on health promotion to improve health indicators in the country. Under political obligations, the Mandela government built on further and undertook comprehensive health sector restructuring to make it more equitable and responsive. Not only health coverage and human resources were streamlined but also innovative health financing schemes were introduced. Private sector participation was encouraged besides enhanced emphasis on prevention.
By the time apartheid ended, tobacco industry was deeply rooted in political economy of South Africa where academic collaborations and anti-tobacco advocacy were gaining ground since 1970. While political environment changed, pressure groups and lobbyists were throwing their weight behind new regime. Around the same time, anti-tobacco sentiment and public awareness had intensified in developed world. Historically, tobacco industry in South Africa responded to these challenges posed by individuals and institutions through economic muscle and political influence. Various front groups and institutes were established to promote counter-science in order to challenge epidemiological studies and smoking-related mortality and morbidity. Despite of efforts to promote tobacco cessation by public health activists, the industry had successfully managed to block anti-tobacco policies and legislations as profits soared at all time high. By 1993, anti-tobacco lobbies and international networks managed to create sufficient political pressure on President FW de Klerk, only to find advertising exemptions and loopholes in resulting legislation. Furthermore, most legislators including agricultural minister distanced themselves from ongoing debate and even opposed anti-tobacco bill.
Arrival of national government in 1994 resulted in prioritizing healthcare through improved primary healthcare, prevention and tobacco control. President Mandela took personal interest in health promotion directed against tobacco and alcohol. Health Minister Zuma attempted to tighten anti-tobacco laws which restricted tobacco advertisements and increased sales taxes. The ANC government outlined ambitious goals of aggressive advocacy campaigns and cessation programs to deliver on political promises of better healthcare and tobacco-free South Africa. The tobacco industry resisted these efforts through time-tested connections with mass media and accused government of violating proprietary rights of registered trademarks. Tobacco barons further argued over higher taxation implying that jobs will be lost and smuggling would increase. Despite of intent and political will, ANC was only partially successful in achieving anti-tobacco goals and by 1996, Minister of Health was wondering if priorities needed to be re-defined and focus be shifted to other healthcare issues such as maternal and child health, communicable diseases, health information systems etc.
It may be argued that efforts to reduce tobacco consumption might have been more effective if the ANC government had translated research into legislation through gradually shaping favorable public opinion. A sociopolitical issue like smoking and its economic dimensions necessitate overwhelming scientific evidence which must be effectively communicated to public. Recognizing rights of non-smokers by reducing exposure to passive smoke and clean air-quality laws seem more appropriate and sustainable in case of South Africa. Direct confrontation with tobacco industry may divert valuable resources and efforts of the government. Nevertheless, focus must remain on reducing morbidity and mortality associated with smoking since it offers enormous economic and health gains. Therefore, a comprehensive tobacco control strategy must include
1. Individual approach using health promotion that targets smokers and potential smokers
2. Promoting healthier change in communities and political structures
3. Increasing population knowledge about effects of smoking and effective use of media
4. Build evidence base for tobacco associated mortality and morbidity
5. Shaping favorable environments through legislations and societies
6. Product regulations as envisaged in FCTC
7. Product regulations and trade barriers against tobacco products
8. Litigations and enhanced funding
9. Thorough economic evaluation, monitoring of industry and continuous impact assessment