OLIVER DICKSON | Public health without science, compassion and common sense is just policy theatre

South Africa can turn years of debate into action by embracing evidence-based policies that save lives and ease the strain on public health.

It is trite that cigarette smoking makes people sick, places a heavy burden on the healthcare system and sometimes kills. We’ve been told this for decades, yet barely any practical steps have been taken, whether in policy or in practice, to get fewer people to smoke cigarettes despite the fact that science tells us less harmful alternatives exist. We need to address this.

A 2021 study titled The Economic cost of smoking in South Africa found that the cost of smoking-related illness to the South African health-care system is about R42bn a year with more than 4% of health care in the country going towards smoking-related illnesses. We’ve learnt over the past decade that not all nicotine products carry the same risk and that smoking-related illnesses emanate from myriad toxins that cigarettes contain rather than nicotine itself. We have sufficient credible scientific data that lawmakers can rely on.

We have a rare opportunity to shift from performance politics to evidence-based health policy, and we shouldn’t squander the moment. In recent weeks, at a PBF health colloquium, Gauteng health leaders publicly embraced harm reduction as a guiding principle for policymaking. That matters. It signals a move away from moral theatre and towards practical steps that measurably reduce illness and death.

If we are serious about saving lives and strengthening a brittle public health system, then science, not sentiment, must lead our policy direction on tobacco, alcohol and other substances.

A harm-reduction based approach is not a controversial idea elsewhere. In markets such as the UK, New Zealand and even Portugal, it’s mainstream public health: you don’t wait for perfect behaviour; you design for the world as it is, meet people where they are and reduce the risk.

South Africa, on the other hand, has talked tough while moving painfully slowly. We set ambitious targets, pass sweeping legislation, then underfund the tools and instruments that produce outcomes. That is the “science gap”, the unnecessary distance between global evidence and local policy execution.

The health experts’ recent endorsement is therefore more than rhetoric. It is a political permission slip for the rest of government to put evidence first. When ANC treasurer-general and former Gauteng health MEC Dr Gwen Ramokgopa cautions us that “South Africa cannot afford to let ideology stand in the way of evidence” she is not speaking in the abstract; she is recalling the exact choices that helped us bend the HIV curve: condoms, testing, treatment and non-judgmental services that met people where they were. Seatbelts reduced road deaths without banning cars. Lower-sugar reformulations improved diet without banning bread or soft drinks. That is harm reduction in practice, a principle and practice that works.

Acting Gauteng health COO Dr Percy Mkhulu Selepe noted: “As government, we are convinced that science must lead policy.” He’s right. We cannot regulate by headline or legislate by intuition; we must measure what actually reduces hospital admissions, disease burden and unnecessary early death and prioritise those interventions.

Nowhere is this more urgent than in the national tobacco debate. The conversation has become polarised in the extreme by those who want to ban tobacco products altogether and those who believe the state should not interfere at all, with too little room for the sensible middle ground where public health usually wins. Harm reduction is that middle ground: discourage initiation, protect children, help people quit, and for those who don’t or won’t, shift them to significantly less harmful alternatives.

If we do this, the payoff will be real. Fewer admissions for smoking-related illnesses. Fewer lives cut short. A lighter fiscal load on a public health system that’s already stretched thin.

It is possible to hold these truths at once: smoke-free nicotine products are not safe; children must be protected; and, for adult smokers who would otherwise continue, regulated alternatives present lower risk than combustible cigarettes. That balance is the only credible path to fewer cancers, less burden on the public health system and fewer deaths.

We have walked this road before. There are non-negotiables: regulation must be grounded in empiricism rather than fear-mongering and protecting minors is key. Vendors who sell nicotine products to children should face the same sanctions that apply to cigarettes; advertising should never target teens; and simple, enforceable rules like ending sales through unattended vending machines should be taken serious. But an outright ban on all communication about smoke-free products risks a perverse outcome: adult smokers remain uninformed about lower-risk options that could reduce demand on our already fragile health system.

The pending Tobacco Bill sits at the crossroads of ideology, lobbying and science. If parliament allows noise to drown out evidence, we will repeat old mistakes: over-promise, under-deliver and watch preventable disease continue to sap our clinics and our economy.

If, instead, lawmakers anchor the bill in harm-reduction science, they can write rules that do three simple things: keep nicotine out of children’s hands; shift adult smokers who won’t quit away from combustion; and mandate honest product communication, packaging and retail channels. Gauteng has now sketched the posture. National policy should follow.

Of course, there is resistance. Some of it is moral virtue signalling, the paternalistic instinct to punish or shame people who use substances. Some of it is institutional, as Prof Monique Marks argues ― we hyper-focus on “supply reduction” and “demand reduction” but neglect the practical services that meet people where they are. That neglect shows in outcomes and budgets alike. We should listen. Meeting people with compassion and evidence-based options is not permissive; it is effective.

So what would a harm-reduction-informed tobacco policy actually look like?

First, protect the kids. No sales to minors, no youth-targeted flavours or marketing, no vending-machine sales, strict age-verification at retail and real penalties for violations. We already accept these principles for cigarettes, we need to apply them consistently.

Second, regulate by risk. Categorise combustible products like cigarettes as the highest-risk category and regulate it accordingly. For adult smokers who won’t quit, encourage access to lower-risk nicotine products like smoke-free tobacco products.

Third, empower users with information and sensible communication. Ban and punish youth-directed advertising, but permit sober, fact-based communication to adult smokers about risk and alternatives, not ineffectual lifestyle campaigns but clinically grounded information that empowers smokers to make better choices. A blanket ban on all communication is not public health, it’s policy theatre.

Finally, keep the coalition broad. The point of public health is not to win a culture war; it is to save lives. That requires industry compliance, academic independence, civil-society trust and government leadership. “The role of these platforms is to ensure that we all communicate and talk together,” Ramokgopa reminded us. That is the tone we need: tough on standards, open to new information and focused on measurable goals.

If we do this, the payoff will be real. Fewer admissions for smoking-related illnesses. Fewer lives cut short. A lighter fiscal load on a public health system that’s already stretched thin. And a politics that finally looks like leadership: principled, pragmatic, measurable.

We know this playbook; we used it to fight HIV, to improve road safety, to reformulate food. We can do it again for tobacco if we allow science and compassion to pull in the same direction. That is the promise in Gauteng’s stance. The rest of the country should seize it.

South Africa has debated harm reduction for years. Now we have a chance to do it. To borrow Ramokgopa’s framing, nobody is banning cars, we are simply insisting on seatbelts. The sooner national policy reflects that common sense, the sooner our clinics, our budgets and our families will breathe easier. Science plus compassion equals progress.

Oliver Dickson is a renowned debate champion and an award-nominated radio broadcaster and TV presenter