CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 4, July/August 2022 AFRICA 205 a similar preference for papsak wine consumption to people between 35 and 44 years of age, and that this was significantly higher than those in the younger age groups.46 Although banned in 2007, papsak refers to cheap white wine packaged in a soft bag, consumed widely by poorer South African communities. This study also noted that alcohol use shifted to misuse as people grew older. A study in rural Limpopo reported a 9.2% prevalence of alcohol consumption (having had a drink in the last 12 months) in participants between the ages of 45 and 54 years, and a 12.6% consumption in those between 55 and 64 years of age.26 Homebrewed alcohol is also common among poorer communities.47,48 Policy developments over the last 10 years have included the drafting of the Control of Marketing of Alcoholic Beverages Bill and its approval by the national cabinet in 2013. To date the draft bill has still not been gazetted for public comment or tabled in parliament.49 This proposed legislation would ban alcohol advertisements in all places except where alcohol is sold. Other proposals have included reducing the blood alcohol level allowed for drivers to zero, an increase in the legal age of drinking to 21 years of age as part of the draft Liquor Amendment Bill, and stricter regulations around the marketing and sale of alcohol.50 In order for alcohol policies to be implemented and effective, they need government support, which is also critical in continuing to resist industry. There should be a focus on peer influences, and interventions should be multi-pronged, focusing on enforcing laws that prohibit alcohol sales to minors, and ensuring that advertising campaigns that target young people are stopped.51 The COVID-19 pandemic and the impact of subsequent lockdowns on alcohol consumption has highlighted the harmful effects of alcohol, resulting in an increase in trauma cases presenting at hospitals, gender-based violence and non-natural deaths. Government’s response is to re-visit the Liquor Amendment Bill drafted in 2017, and there has been a recent increase in alcohol tax. As there is recent national and regional prevalence data on alcohol consumption for this age group, the grade assigned for the availability of prevalence data is an A (Table 2). As several policies have been proposed but not implemented, a grade C is assigned to the policy and implementation component for alcohol (Table 3). Tobacco use In 2019, the WHO reported that there were 1.3 billion tobacco users in the world, of which 80% lived in LMICs.52 In line with the Global Action Plan for the Prevention and Control of NCDs,53 the fifth target of the NCDs Global Monitoring Framework established in 2011 aims by 2025 to reduce by 30% the prevalence of current tobacco use in persons of 15 years of age and older.36 In South Africa, it is estimated that 75% of trachea, bronchus and lung cancer deaths, 65% of chronic obstructive pulmonary disease deaths, 18% of CVD deaths and 15% of tuberculosis deaths are attributable to tobacco use.54 In 2013, the South African Declaration for Prevention and Control of NCDs committed to reduce the prevalence of tobacco use, estimated in 2009 at 23.7% (36.7% of men and 10.3% of women), by 20% by 2020.5 Following global trends, national data from South Africa has reported that the prevalence of tobacco smoking among persons aged 15 years and older declined between 2005 and 2015.55 However, high rates of tobacco usage were observed among persons in the 40- to 69-year age range, and particularly in men.8,9,56 The prevalence of tobacco smoking among men and women in the 45 to 65 years age ranges was higher than the adult national prevalence, at approximately 20% in 2012 and approximately 22% in 2016.9,57 In addition, SANHANES 2012 and SADHS 2016 reported gender differences in the prevalence of tobacco smokers in the 45- to 54-year age group (SANHANES 2012: men 35.8% vs women 8.5%; SADHS 2016: men 44.7% vs women 9.1%) and the 55- to 65-year age group (SANHANES 2012: men 29.4% vs women 11.3%; SADHS 2016: men 37.3% vs women 10.1%).57 South African data pertaining to tobacco use, which includes smoke and smoke-free products, published between 2013 and 2020 can mainly be found in cross-sectional surveys including: secondary analyses of nationally representative surveys (n = 6),8,9,57-63 large standardised multi-wave cross-country surveys (n = 19) comprising WHO-SAGE27,39,43,61-66 and the PURE study,23,40,41,47,67-72 a public dataset (n = 1)73 and regional studies (n = 11).26,74-81 Of those, only a few surveys (n = 7) specifically reported information in the 45- to 65-year age group27,28,39,57,73,74,77 and the majority (n = 30) were not designed to focus primarily on tobacco use, its prevalence and aetiology, but rather to investigate the role of tobacco use in NCD risk in broad adult populations, which were only collected using self-reported questionnaires such as the WHO STEPwise questionnaire82 or other tools designed for survey purposes. The WHO-SAGE wave 1 survey reported smaller gender differences than the national surveys, as well as a lower prevalence in men (25.8% for 50 to 59 years old and 21.4% for 60 to 69 years old), and a higher prevalence in women (17.3% for 50 to 59 years old and 14.9% for 60 to 69 years old) 27,39 compared to national data. The use of other tobacco products (hand-rolled cigarettes, pipes, cigars, water-pipes, electronic cigarettes, snuff, chewing tobacco and smokeless tobacco) was also reported to be higher among men than women within the 45- to 65-year age group (~7% in men and 4–6% in women).57 Regional data has reported ethnic disparities in tobacco use in the 45- to 65-year age range. A study of persons who self-identified as Indians living in Durban reported a 20 to 30% prevalence of tobacco use, and a study of self-identified African men and women from a socio-economically deprived neighbourhood in Cape Town reported a prevalence of 35 to 44% in men and approximately 10% in women.74 A case–control study of 481 640 deaths in the South African population reported that the highest smoking-attributed mortality rate was observed in persons who self-identified as coloured (of the 45- to 64-year-old deaths, 60 to 71% were of smokers) and the lowest in persons who self-identified as African (of the 45- to 64-year-old deaths, 42 to 53% were of smokers).73 In South Africa’s Strategic Plan for the Prevention and Control of NCDs (2013–2017),4 which is in line with the six MPOWER measures,83 and the practical and cost-effective interventions of the WHO Framework Convention on Tobacco Control implementation,84 it has been recommended that South Africa monitor tobacco use and tobacco-prevention policies; protect people from tobacco smoke in public places and workplaces; offer help to people who want to stop using tobacco; warn people about the dangers of tobacco; enforce bans on tobacco advertising, promotion and sponsorship; and raise tobacco taxes and prices.4
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