Aids denialism – the government’s refusal to acknowledge HIV as the cause of Aids, and as a result provide people living with HIV with lifesaving antiretroviral (ARV) treatment – may have cost at least a third of a million South Africans their lives.

That’s how many people would probably not have died of Aids, had they had access to treatment.

Now lobbyists pushing for vaping as a way to help people quit smoking insist taxing e-cigarettes like traditional smokes is leading down a similar path. 

The argument has been smouldering in different forms since 2018 when the health department announced its plans to regulate conventional cigarettes and next-generation products, such as vapes and heated-tobacco products, in the same way (under the now-stalled Control of Tobacco Products and Electronic Delivery Systems Bill). If the law were to pass, the same plain packaging rules and advertising bans would apply to old-school tobacco and e-cigarettes, and you’d have to ask for your fix at a shop counter rather than picking it off the shelf yourself. 

So when the Treasury invited comment in December on its plans to impose a sin tax on e-cigarettes from 2023, it was a spark to a flame because the pro-vaping lobby argues it creates the impression that tobacco and next-generation products are equally bad.

Although excise taxes (fees levied on products such as alcohol that people buy often) are paid by product manufacturers the charges often affect consumers because they lead to higher prices at the till. 

If the new tax plan goes through, the pro-vaping lobby (comprising researchers, doctors, tobacco and vapour products companies) says smokers will be cheated out of a longer life because of policies that are based on fearmongering about nicotine alternatives instead of science. 

But comparing a tax on a behaviour-changing substitute that is yet to be widely confirmed to denying people life-saving medicine backed by solid science flummoxed the HIV experts, ethicists and legal minds Bhekisisa spoke to. 

In this article, the second in our series on this public health tug-of-war, we untangle the intricacies of the denialism argument. 

A blast from the past

For nearly 10 years, from 1999 to 2008, the South African government largely denied that Aids was a disease caused by a virus called HIV.  

The country’s decision-makers at the time – former president Thabo Mbeki and his health minister, Manto Tshabalala-Msimang – claimed poverty, malnutrition, haemophilia (a blood disorder) and drug use were responsible for the devastating number of deaths Africa was seeing at the time. In 2005 alone, Aids deaths were estimated at  2.4 million. The government portrayed AZT, by then a proven antiretroviral treatment, as poisonous and even claimed that it caused Aids.

In 2000, Mbeki set up an advisory panel that was made up of just as many HIV denialists as Aids researchers. A prominent dissident on the panel – Peter Duesberg, a US-based cancer researcher who was one of the first to discover the virus group to which HIV belongs (retroviruses) – was particularly influential in convincing Mbeki that HIV was harmless, and people were therefore not dying of Aids.

The former head of state has never recanted his views. 

A twis(p)t on the theme 

The vaping lobby’s parallel with HIV denialism comes from Kgosi Letlape, a local doctor who formerly headed the Health Professions Council of South Africa (the body with which most health professionals have to register before they’re allowed to practice in the country). He’s also a commissioner for the Foundation for a Smoke-Free World, which is funded solely by the tobacco company, Philip Morris International. 

In Letlape’s opinion, miscasting a possible solution to long-term cigarette use as “just as bad or worse” than old-fashioned tobacco products, reminds him of the time when denialists propagated that ARVs were more harmful than HIV. 

“That wasn’t true. If people had Aids-defining illness and they got HIV treatment, they lived. Without it, they died. And it’s the same with people who are addicted to combustible cigarettes,” Letlape argues. 

In a nutshell: Smokers who can’t quit need affordable access to alternatives to stay alive. 

Letlape also says the increased cost of vapes (because of higher excise taxes) will lock most smokers in South Africa – who, according to him, are mainly  poor – out of a “better” option. This mimics the inequality of access to HIV treatment in South Africa’s public and private health sectors during the Mbeki era, he says. 

But a study of more than 18,000 South Africans published in the medical journal Family Medicine and Community Health in 2021 found that most smokers in the country are, in fact, not poor – the research showed that smoking rates were similar regardless of how much people earned.  

The authors also argued that in South Africa, there aren’t enough smokers who can’t or won’t quit to warrant actively promoting “safer” products such as vapes for the entire population. 

Only 6% of all smokers don’t want to or can’t quit – and even in this group people were open to trying again if they experienced a health scare such as a life-threatening lung disease.

Of apples and oranges: ARVs vs nicotine alternatives 

Ethicists and public health advocates say the comparison with Aids denialism is a non-starter. 

“It’s a misguided attempt to elevate the moral standing of the tobacco industry,” explains Jerome Singh, a professor of law and ethics at the University of KwaZulu-Natal. 

For one, ARVs as a life-sustaining medicine are backed by years of evidence, he says. In contrast, the jury is still out on the science of e-cigarettes as an effective way to wean people off tobacco. 

Also, Mbeki’s HIV denialism was turned into national policy, which meant it was impossible for people in the public sector to access treatment that would certainly save them. 

That’s not the case with tobacco use in the country. 

Reducing the harms of tobacco use is written into South Africa’s action plan on noncommunicable diseases (which has been in the pipeline for eight years and is still only in draft form). Noncommunicable diseases are illnesses such as diabetes which can be genetic or at least partly caused by the way people live their lives, so they’re not passed from one person to another by an infection. 

The government also funds research into tobacco use and prevention through the South African Medical Research Council’s unit on tobacco, alcohol and other drugs. This team tracks patterns in drug use across the country, monitors how many people are admitted to treatment centres and publishes regular reports as part of the South African Community Epidemiology Network on Drug Use.   

But people on both sides of the argument seem to agree that the government is not doing enough for those who want to quit tobacco.

For instance, both Letlape and researchers who are firmly in the public health camp say South Africa needs better psychological counselling services for people who want to stop smoking, that overall quitting services are lacking, and that quitting aids (such as nicotine replacement therapy) need to be cheaper or free at state facilities. 

“Changes in legislation [like imposing an excise tax] are the only intervention the government ever makes when it comes to noncommunicable diseases,” says Vicki Pinkney-Atkinson, who heads the South African Non-communicable Disease (NCD) Alliance. 

Changing laws is the quickest and cheapest way to bring down use of substances on a population level, but that also means that such plans remain with the national health department, and no funding is made available for provinces, she says. 

The country’s financial plan until 2024 reads: “There is no budget for addressing noncommunicable diseases.” The document says funding from international aid organisations such as Pepfar (the US President’s Emergency Plan for Aids Relief) must be used instead.  

In January, the NCD Alliance filed a complaint with the country’s Human Rights Commission, accusing the health department and presidency of neglecting people with NCDs such as tobacco-related illnesses because they have failed to implement proper policies and to secure the funding such plans would require.

But, Pinkney-Atkinson says, arguments that not enough is being done to support people who want to quit tobacco don’t justify drawing a moral parallel with the state-sanctioned denial of effective treatment during the Mbeki years. 

“The industry is grasping at straws because they’re going to lose money.”

The power of public doubt

Claims from people aligned with the tobacco industry about the government being science denialists have a skin-crawling ring to them. 

Why? 

Because the tobacco industry invented science denialism.

In the 1950s, big tobacco businesses geared up to fight regulatory crackdowns by governments around the world. They needed a public relations ploy that would undermine scientific research showing that smoking causes cancer, and thereby slow policy change as a result. 

The strategy they devised was so successful that schemes based on this tactic have since also been used by other industries needing to harness the power of public doubt. Such tactics are so common in the lobbying world that researchers have come up with a shorthand to describe it: Scam, for “scientific certainty argumentation methods”. 

Take, for instance, oil companies reframing the contribution of human activities to climate change as just a theory, rather than a fact. 

That plan worked because it exploited semantics. Scientists and lay people use language differently, writes Susan Hassol, who specialises in explaining the science of climate change to policymakers. She was tasked with translating this science for the United States government. 

Scientists, she explains, use the word “theory”, for instance, to describe a concept that is accepted as fundamentally true – like the theory of gravity – because it’s been tested many times in many different ways, and the outcome is always the same. But to everyday readers a “theory” is nothing more than a hunch. 

Because such tactics earned the tobacco industry the label of liars, it’s understandable that policymakers would scrutinise harm-reduction claims made by groups linked to tobacco very critically, explains Mitchell Warren, the executive director of the AIDS Vaccine Advocacy Coalition. 

So, the tobacco industry is equating scepticism on the part of the public health lobby because of a lack of conclusive evidence to simply refusing to accept new research findings. 

This, the tobacco lobby argues, is similar to Aids denialists’ strategy of moving the bar for evidence that ARVs work higher and higher the more information becomes available, and is simply counterproductive.  

Disagreement versus denial 

Letlape is frustrated about how the fight about the science behind vaping as a possible safer smoking alternative is playing out. “We have a way of dealing with disagreements in health. We follow the evidence,” he says.

Vaping proponents maintain that the e-liquid used in vapes is far less harmful than the fumes from traditional cigarettes. Letlape therefore argues they shouldn’t be framed as equally dangerous.  

He says the other team – in this case, the health department, public health researchers and the Treasury – refuses to accept that there are safer options for smokers because it’s easier to accept that all tobacco products are bad. And this, he reckons, hamstrings people who are trying to kick the habit. 

However, modelling studies show that even a “safer” smoking product holds more harm than benefit when it comes to population health. A study published in the journal PLoS One worked on the assumption that e-cigarettes are 95% safer than traditional smokes. Even so, e-cigarette use in 2014 would lead to about 1.6 million years of life lost in the US alone.

Cloaking disagreements about science in the language of denialism is dangerous, counters Warren. “Analogies can often play tricks on people, so the language really matters.” 

Aids denialism is a type of pseudoscience, and claiming that the government is engaged in junk science is inaccurate, Warren says, especially when it is, in fact, doing the opposite by sticking to the science backed by the clearest evidence.  DM/MC

In the following instalments of this series, Bhekisisa will look at the way society views nicotine use, and how it fits into moral arguments about addiction and harm reduction.

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.