South Africa will struggle to eliminate tuberculosis (TB) and fully protect people living with HIV if tobacco use and rising nicotine addiction are not urgently addressed, argues Professor Lekan Ayo-Yusuf, Head of the School of Health Systems and Public Health at the University of Pretoria and Director of the Africa Centre for Tobacco Industry Monitoring and Policy Research.
As the country marks World No Tobacco Day on 31 May, the warning comes at a time when South Africa has made major gains in extending the lives of people living with HIV through improved treatment and care. However, these gains are increasingly being challenged by the growing burden of non-communicable diseases such as cancer, heart disease, and chronic respiratory illness—many of which are directly linked to tobacco use.
According to Ayo-Yusuf, tobacco smoking is not only a major cause of chronic disease but also a significant driver of TB infection and poor treatment outcomes. Research, including studies involving South African populations, shows that tobacco smoke weakens the immune system, making it harder for the body to fight TB infection. It also increases the likelihood of death among those already diagnosed with the disease. Emerging evidence suggests that nicotine exposure from vaping products may also negatively affect immune responses, raising further concerns about the rapid rise of e-cigarette use.
This is especially alarming in South Africa, where TB and HIV remain deeply connected public health challenges. Recent modelling studies even suggest that among people living with HIV who are virally suppressed, smoking may reduce life expectancy more than HIV itself.
Despite these risks, the country has seen a rapid expansion of nicotine products, particularly vaping devices. Vape shops have multiplied across urban areas, while social media marketing and flavoured disposable vapes—often containing high concentrations of nicotine salts—are increasingly targeted at young people. Critics argue that these products are being marketed as “harm reduction” tools, but Ayo-Yusuf questions whether they are truly reducing harm if they are attracting teenagers who might otherwise never have smoked.
Over the past decade, South Africa has effectively become a large-scale case study in the effects of largely unregulated nicotine product growth. Survey data indicates rising levels of vaping among young adults, alongside continued cigarette and hubbly smoking. In many cases, individuals are not replacing cigarettes with vaping but using both, raising concerns that overall nicotine dependence is increasing rather than declining.
At the centre of the debate is the Tobacco Products and Electronic Delivery Systems Control Bill, first introduced to Parliament in 2022. The proposed legislation does not ban cigarettes or vaping products. Instead, it aims to introduce stricter regulation, including stronger smoke-free laws, tighter controls on advertising and packaging, and measures designed to reduce youth exposure to nicotine marketing. Many countries have implemented similar policies as part of broader tobacco control strategies.
However, the Bill has faced strong opposition, with critics raising concerns about illicit trade, job losses, and personal freedom. Ayo-Yusuf argues that such claims are often amplified by industry-linked interests and distract from the public health benefits of regulation. He also notes that illicit cigarette trade in South Africa predates recent tobacco control efforts and is largely driven by weak enforcement and under-reporting rather than regulation itself.
The economic argument is also central to the debate. While opponents warn of job losses, public health experts highlight the far greater economic burden caused by tobacco-related diseases, which cost the country billions of rand annually and contribute to tens of thousands of premature deaths each year.
For Ayo-Yusuf, the issue is not whether tobacco control should exist, but why South Africa should accept weaker protections than countries such as the United Kingdom or Uganda, where similar or stronger regulations are already in place.
Ultimately, he argues that South Africa faces a critical choice: allow nicotine addiction to continue expanding, especially among young people, or implement evidence-based policies that protect future generations. Passing the Bill, he concludes, would not solve every health challenge, but it would be a crucial step toward reducing TB, cancer, heart disease, and addiction in the long term.
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