Article Text

Framing the policy debate over tobacco control legislation and tobacco taxation in South Africa
  1. Mateusz Zygmunt Zatoński1,2,
  2. Catherine O Egbe3,4,
  3. Lindsay Robertson1,5,
  4. Anna Gilmore1
  1. 1Department for Health, University of Bath, Bath, UK
  2. 2European Observatory of Health Inequalities, Calisia University, Kalisz, Poland
  3. 3Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Pretoria, Gauteng, South Africa
  4. 4Department of Public Health, Sefako Makgatho Health Sciences University, Pretoria, Gauteng, South Africa
  5. 5Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
  1. Correspondence to Dr Mateusz Zygmunt Zatoński, Department for Health, University of Bath, Bath BA2 7AY, UK; zatonski.mateusz{at}gmail.com

Abstract

Background In 2018, South Africa opened public consultations on its newly proposed tobacco control bill, resulting in substantial public debate in which a range of arguments, either in favour of or against the Bill, was advanced. These were accompanied by the recurring discussions about the annual adjustments in tobacco taxation. This study uses the concept of framing to examine the public debate in South African print media on the potential effects of the legislation, as well as tobacco tax regulations, between their proponents and detractors.

Methods A systematic search of news articles using multiple data sources identified 132 media articles published between January 2018 and September 2019 that met the inclusion criteria.

Results Seven overarching frames were identified as characterising the media debate, with the three dominant frames being Economic, Harm reduction and vaping, and Health. The leading Economic frame consisted primarily of arguments unsupportive of tobacco control legislation. Economic arguments were promoted by tobacco industry spokespeople, trade unions, organisations of retailers, media celebrities and think tanks—several of which have been identified as front groups or third-party lobbyists for the tobacco industry.

Conclusion The dominance of economic arguments opposing tobacco control legislation risks undermining tobacco control progress. Local and global tobacco control advocates should seek to build relationships with media, as well as collate and disseminate effective counterarguments to those advanced by the industry.

  • media
  • tobacco industry
  • public policy
  • advocacy
  • low/middle-income country

Data availability statement

Data are available upon reasonable request.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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Introduction

The media often play a crucial role in policymaking. They can influence agenda setting (whereby some concerns rise to the attention of policymakers), draw the public’s attention to certain issues and help convey public attitudes to decision-makers.1 2 Media frequently inform the discourse around a policy debate by framing an issue in a particular way, which can condition perceptions of the appropriate policy solution(s) to that issue, and hence the policies regulators progress.3 Media can also potentially highlight the actors involved in the policy process and can aid or hinder their cause by drawing attention to their activities.2

Analyses of framings employed in public health debates are essential to strengthen public health advocacy efforts, particularly in tobacco control policymaking, which involves an increasingly complex array of competing stakeholders (eg, local and transnational tobacco manufacturers, business associations, electronic cigarette (e-cigarette) manufacturers, e-cigarette advocacy groups, retailers, tobacco growers, and health and welfare organisations).

Although some research has examined how arguments supporting or opposing tobacco control policies have been framed, these studies have mainly been conducted in high-income countries with progressive tobacco control policies.4–7 In Africa, where demand for cigarettes is projected to keep increasing,8 9 and where implementation of tobacco control measures is relatively limited,10 few studies have explored how tobacco control has been represented in the news media.11 12

In May 2018, public consultations were opened on South Africa’s (SA) proposed Control of Tobacco Products and Electronic Delivery Systems Bill (hereafter ‘the Bill’).13 The proposed legislation would remove designated smoking areas in restaurants and other public places, introduce standardised packaging with graphic health warnings, remove cigarette vending machines, ban point-of-sale tobacco marketing (making it illegal to display tobacco products at the point of sale in retail venues), and regulate e-cigarettes and heated tobacco products as tobacco products.14

As previous research in SA has demonstrated that English-language newspapers are influential with the public and policymakers in agenda setting,15 16 we examined the public debate around the Bill that ensued in SA print media, exploring how competing stakeholders framed their position and sought to dominate the debate.

Methods

We used the LexisNexis news archive to conduct a systematic search of news articles published in SA newspapers between 1 January 2018 and 16 September 2019, using terms ‘South Africa’ and ‘tobacco’. LexisNexis contains more than 4 billion searchable documents from tens of thousands of sources, and allows users to retrieve articles specific to a country of interest. We supplemented this search with a Google Alert for the same keywords from 2 April 2019 (when this research project was started) to 16 September 2019, and through the ‘find similar’ function of PressReader. SA has a vast multilingual media landscape, however only English-language newspapers were included in the searches due to their wide and varied readership and influence with policymakers,15–17 as well as the pragmatic advantage of not requiring resources for translation.

We identified and scanned 2082 (LexisNexis) and 44 (Google Alert) articles. We included articles (n=132) that referred to the Bill specifically in the title or body of article, and to tobacco tax regulations discussed alongside the Bill; we excluded articles that only referred to illicit tobacco or track-and-trace systems without mentioning the Bill. The Bill did not include a price component, but since tobacco taxes are adjusted annually by the SA National Treasury (under the Ministry of Finance), the public discussion on cigarette taxation closely accompanied the debate on the Bill and was included in the analysis.

For each article, we extracted the publication date, author, newspaper name, individuals and organisations mentioned, and any mentions of events relating to tobacco control and tobacco regulation (including policy reviews, tobacco control conferences, releases of studies and surveys evaluating the regulation, anti-regulation campaigns). The Tobacco Tactics website (a resource containing profiles of the tobacco industry’s key personnel, organisation and allies), which is curated by an academic institution and is rigorously sourced applying academic standards of evidence, was consulted for any links the identified organisations and individuals might have with the tobacco industry.18

Articles were first read by MZZ for data familiarisation and an initial coding framework capturing arguments organised under five conceptual, overarching frames (economic, health, moralistic, historical, political/legislative) was drafted based on previous research on the framing of policy debates over the regulation of unhealthy commodities, including tobacco and alcohol.19 20 Descriptive accounts of the identified arguments were developed and the most frequently recurring specific arguments were grouped under the relevant frames (for full list of arguments, see online supplemental table 2). MZZ and LR tested the initial codebook with a random sample of n=10 articles and as a result, two additional frames were identified inductively (international and harm reduction). The double-coding also served as a training exercise before MZZ reviewed the coding categories and processes. Following the double-coding, MZZ consulted the complete list of codes with COE, who served to refine and finalise the wording of the categories and contextualise them for the South African context. MZZ then coded the remaining articles using NVivo. Throughout the process, the authors periodically reviewed and discussed the coded data for consistency.

Articles were assessed for whether they were broadly supportive (contained more positive than negative statements), unsupportive (vice versa) or neutral (they did not contain any value judgement) towards tobacco control. Descriptive analyses were used to present the frequency of media articles across the covered period, by frame and by support for tobacco control regulation.

Results

The included 132 articles were published in seven calendar quarters (Q1–Q7) between January 2018 and September 2019, in 31 news media outlets. They reported on key events surrounding tobacco control in SA, including milestones in the progress of the Bill, changes in tobacco taxation, and campaigns and events organised by supporters and opponents of tobacco control regulation (event timeline is presented in table 1). Descriptions of organisations most frequently mentioned in the articles, their stance towards the Bill and tobacco control regulation, and any known links with the tobacco industry are presented in online supplemental table 1. Organisations supportive of the Bill were primarily research and advocacy civil society groups and parastatal organisations, as well as academic research units. Organisations unsupportive of the Bill were pro-vaping groups, farmers’ and labour organisations,tobacco industry associations and libertarian groups. Among the included organisations critical of the tobacco control measures, 7 out of 10 had previously evidenced links with the tobacco industry.

Table 1

Timeline of key events in tobacco control in South Africa by calendar quarter

Analysis of dominant frames

Seven overarching frames, each composed of several distinct arguments, were identified as characterising the public debate on tobacco control. The three dominant frames were Economic, Harm reduction and vaping, and Health. A summary of the most frequent arguments (mentioned in at least 10% of the articles analysed) is presented in table 2 (the full list of arguments and their frequency is available in online supplemental table 2). Media articles referenced in the text are numbered S1–S32, and their full details are available in the online supplemental file.

Table 2

Summary and frequency of arguments, by frame

Economic frame

The most common argument was that further tobacco control legislation would contribute to increasing illicit trade in SA. This argument was deployed not only to criticise the Bill, but also the annual increases in cigarette taxation. On the eve of a tax increase in February 2019, the Black Tobacco Farmers Association (BTFA) issued a statement criticising the decision: ‘It is hugely disappointing that Treasury has offered no help at all but instead decided to make things easier for tax dodgers by increasing tax again on the legal industry’ (S1). This argument was also used to criticise other provisions of the Bill, such as plain packaging.

AgriSA, the Food and Allied Workers Union (FAWU) and the SA Spaza and Tuckshop Association (SASTA) said on Tuesday that the bill would “devastate SA’s agriculture and township businesses”. The plain packaging provisions would boost the illicit cigarette trade […]. (S2)

In July 2019, Japan Tobacco International (JTI) released the results of a survey it commissioned claiming that the SA public expressed a high level of concern about plain packaging resulting in negative consequences, such [as] the spike in illegal cigarette sales’ (S3). To coincide with the release of the survey, The Star daily newspaper was published with a blank cover and a four-page spread wrap sponsored by JTI criticising plain packaging (S4).

Another prominent argument, job losses, was often mentioned alongside claims that regulation would harm small businesses and SA farmers. Retailers were reported saying that new laws will lead them to ‘retrench employees’ (S5). The Vaping Products Association of South Africa warned that e-cigarette regulations would stall job creation in the expanding vaping sector (S6). The Tobacco Institute of Southern Africa (TISA) threatened that the new laws would pose a risk to the over 100 000 jobs which the tobacco sector ‘directly and indirectly supported […] of which 8000–10 000 jobs are on farms in deep rural areas […]’ (S7).

The tobacco control community attempted to challenge the anti-regulation messages dominating the Economic frame. One argument supportive of legislation was that smoking is a burden for SA’s economy and healthcare through tobacco-related hospitalisations, productivity loss, premature mortality and the financial impact on SA families. Newspapers quoted the WHO and SA public health researchers that ‘tobacco imposes a heavy economic burden on South Africa, estimated at over R59 billion a year’ (S8). The media also reported research debunking the industry’s claim that regulation leads to illicit trade (S9).

Harm reduction and vaping frame

The most common unsupportive argument in this frame, often brought up by tobacco industry spokespeople and pro-vaping groups, was that regulation of e-cigarettes and novel tobacco products would take away a safer alternative from smokers who cannot quit. The Philip Morris SA Chief Executive urged the government to exempt IQOS (SA was the first African country in which this product was introduced on the market, in 2016),21 from the Bill, explaining that it generates, ‘on average, less than 10% of the levels of harmful constituents found in ordinary cigarettes smoke’ (S10). These claims were echoed by the e-cigarette industry and pro-vaping organisations. Delon Human, a medical doctor with a history of collaborating with British American Tobacco South Africa,22 and co-founder of the Africa Harm Reduction Alliance, argued that ‘Vaping and e-cigarettes have the potential to prevent tobacco-related disease and save hundreds of millions of lives from premature death’ (S11). Another prominent argument was that vaping is not smoking and should not be measured with the same regulatory yardstick (S11).

Several of the arguments within the Harm reduction and vaping frame were supportive of the regulation. The most common of these was that vaping is harmful. Media quoted researchers and the WHO that emissions from heated tobacco products and e-cigarettes contained toxins, metals, nicotine and other harmful and potentially harmful substances’ (S12). Similar sources were cited in relation to the argument that vaping is a gateway for new smokers or leads to dual use. This included a study in the New England Journal of Medicine showing that the majority of e-cigarette users continue to smoke cigarettes (S13).

Health frame

The Health frame comprised arguments supportive of tobacco control, most commonly that smoking is a key driver of premature mortality and morbidity, with tobacco ‘one of the biggest public health threats the world has ever faced’ (S14). This was accompanied by Tobacco Atlas estimates that more than 42 100 South Africans die from tobacco-related diseases each year’ (S15). Tobacco control legislation would help in decreasing the number of people affected by tobacco-related diseases such as lung cancer’ (S16). This argument was also sometimes used to refute the tobacco industry’s economic arguments. Spokespeople of the Department of Health argued that ‘there is no economic development if people are sick or dead’ (S17). The SA Minister of Health put this point more bluntly: ‘are we creating these jobs for corpses?’ (S18).

Another argument focused on the health consequences of secondhand smoke. Media reported that the Bill would ‘decrease the effects of second-hand smoke on the majority of South Africans, who are non-smokers’ (S19). The final argument focused on smoking harm among vulnerable populations. This often took a more emotive tone, with headlines such as ‘Shocking nicotine levels in babies’ (S20). SA officials highlighted the importance of ‘evidence-based tobacco control interventions’ in reaching ‘the ultimate goal of zero initiation for young people’ (S21). Growing smoking rates among women were also singled out as a burning problem (S22) and WHO Africa figures cited that ‘two out of three deaths from second-hand smoke in Africans occur among women’ (S23).

Minor frames

The remaining frames were less prominent, and most were dominated by arguments supportive of the legislation, except for the Political/legislative frame, where unsupportive arguments were more frequent.

Under the Moralistic frame, media referred to the unethical nature of the tobacco industry, and argued that due to its long track record of tax evasion, money laundering, racketeering and corruption’ and opportunistically targeting ‘young people in Africa’ (S24), the tobacco industry should not be allowed to engage in formulating public health policy. A related argument referred to the tobacco industry’s attempts to undermine tobacco control regulation. The SA Minister of Health said that ‘all the signs are there that the tobacco industry is staging a fightback after a slew of tobacco control legislation in the past two decades’ (S25). Journalists also suggested that TISA’s comments should be taken with a grain of salt’ given that the ‘body has a history of pushing policymakers away from any regulations that would affect the tobacco industry’s bottom line’ (S26). The arguments critical of tobacco control regulation within this frame portrayed the Bill as an attack on the freedom of choice.

Under the Historical frame, the media cited the public health success of previous tobacco control legislation in bringing down smoking rates in SA (S27). Media also criticised the tobacco industry’s targeting of Africa, with the WHO Director General quoted in warning that Africa was ‘ground zero’ for tobacco companies, who had identified it as a major growth market’ (S28).

The International frame’s most frequent supportive argument focused on examples of tobacco control regulation in other countries, for example, pointing out that ‘Gabon, the Gambia, Kenya, Senegal and Uganda are Africa’s shining lights in terms of tobacco control interventions’ (S29). The regulations proposed in the Bill were described as reflecting such best practice (S26). The Bill was presented as a step towards SA fulfilling its obligations to the WHO Framework Convention on Tobacco Control (S30).

Finally, the Political/legislative frame was dominated by arguments critical of the Bill, such as the tobacco industry’s claims that proposed tobacco control regulation will not be effective in reducing smoking rates. Smokers were quoted speaking unfavourably about the feasibility of the proposed rules—‘What are they going to do? Arrest all of the smokers?’ (S31). This was often accompanied by the argument that the enforcement of existing regulation should be the priority. In July 2019, JTI sponsored stories promoting the results of its survey showing that rather than focusing on plain packaging, ‘87% of South Africans think it is important to prioritise more effectively enforcing existing rules prohibiting the sale of alcohol and cigarettes to minors’ (S32).

Stance, volume and timing of arguments

Public health advocates made a concerted effort to support the Bill in SA print media. The two organisations mentioned most frequently belonged to the tobacco control community—the National Council Against Smoking (NCAS) was mentioned in 28 articles, and the University of Cape Town (UCT) in 27. Tobacco industry body TISA came third with mentions in 23 articles (see online supplemental figure 1 for number of mentions of different organisations by quarter). In effect, a narrow majority (52%) of all media articles in the period between 1 January 2018 and 16 September 2019 identified in this study took a predominantly supportive stance towards tobacco control regulation. However, almost 40% of these supportive articles were published in Q1, coinciding with a major public health event which drew media attention—the World Conference on Tobacco or Health, held in Cape Town in March 2018. For most of the remaining quarters, media reporting was dominated by articles unsupportive of tobacco control regulation (see figure 1).

Figure 1

Stance of articles towards tobacco control legislation by calendar quarter

The quarters in which unsupportive media coverage prevailed were those in which arguments from the Economic frame outnumbered arguments from the Health frame. This was the case in Q3, which saw the peak in media reporting on tobacco control regulation, when almost one-third (n=37) of all articles included in this study were published (see figure 2). This quarter included an important policy window, namely the period of public comment for the Bill, closing on 8 August 2018. The tobacco industry intensified its activity to ensure its messages dominated the media debate in this period. In July 2018, JTI launched its anti-plain packaging #HandsOffMyChoices campaign, accompanied by print media advertisement and substantial coverage.23 24 At the same time, IPSOS released the TISA-commissioned study showing that illicit trade in cigarettes in SA has skyrocketed since 2014.25 A week later, TISA launched its #TakeBackTheTax campaign, which argued that a further tightening of tobacco control regulations will be counterproductive until SA curbed its illicit cigarette trade. The campaign was well publicised in leading newspapers such as Mail & Guardian and fronted by journalist and anti-crime activist Yusuf Abramjee.26 27 In Q3, TISA became the organisation most frequently mentioned by the media, overtaking UCT and NCAS, and articles critical of tobacco control regulation significantly outnumbered those in favour.

Figure 2

Leading frames as percentage of all codes

Third parties sympathetic to the tobacco industry also appeared to mobilise ahead of specific policy windows. For example, all mentions of the SA Spaza & Tuckshop Association and of the SA Informal Traders Alliance were between 6 and 12 August 2018 (Q3), coinciding with the closing on public comments for the Bill on 8 August 2018. Both organisations were highly critical of the impact the Bill would have on their members. Another organisation, the BTFA, was set up in January 2019,28 with support from British American Tobacco South Africa.29 All its mentions in the media came in January and February 2019, coinciding with the SA Treasury Budget review in late February 2019, and related to the BTFA’s opposition to the planned increase in excise tax in cigarettes.

Discussion

The tobacco control legislation proposed in the Bill remains unenacted at the time of writing in September 2021, an outcome that could be, at least in part, due to the industry’s use of economic arguments to oppose the Bill in influential newspapers, arguments that appear to hold more sway than health-focused arguments.4 19 30–35

Our findings suggest that despite engagement of the SA public health community in the media, actors supportive of, or financially linked to the tobacco industry, have been able to successfully promote and dominate the Economic frame in the debate around tobacco control legislation between 1 January 2018 and 16 September 2019. Economic arguments critical of the Bill were promoted by tobacco industry spokespeople, trade unions, organisations of retailers, media celebrities and think tanks—most of which have been identified as front groups or third-party lobbyists for the tobacco industry. The analysed period included two budget reviews, in February 2018 and February 2019, and the tobacco industry harnessed these events to further highlight the economic arguments in reference to tobacco tax, but also tobacco control more broadly. The tobacco industry concentrated its efforts around specific policy windows, and launched tailored campaigns focusing on criticising individual provisions of the Bill or tobacco tax increases.

Our findings are consistent with evidence of tobacco industry strategies to garner media attention, including by launching tailored campaigns to coincide with policy windows, using third parties to amplify arguments against tobacco control regulation, and promoting its own data on illicit tobacco trade among journalists.20 36–43

The anti-regulation arguments identified in this study are also consistent with previous work on tobacco industry discursive strategies that has largely drawn on data from outside Africa.43 However, we identified several that have not been described before, or are only starting to begin to emerge in the literature,44 including the tobacco industry claim that it is a champion of SA’s black population, or that the local socioeconomic context impedes the introduction of global best practice tobacco control legislation. This provides a warning for low/middle-income country-based tobacco control advocates that while the industry recycles its discursive strategies from previous policy debates, it does carefully adapt them to the local context.

In addition, this is one of the first studies to categorise harm reduction arguments used by the tobacco industry and its allies.45 The tobacco industry has increasingly used its purported commitment to harm reduction to interfere with tobacco control legislation, including but not limited to regulation of e-cigarettes and heated tobacco products, often employing third party groups to lobby on its behalf.46 The findings from SA are an important heads-up for advocates and policymakers of the kind of tobacco industry messaging they should increasingly expect to see in the future.

Implementation of the Bill would make SA the first African country to adopt plain packaging, a policy that has seen extensive tobacco industry opposition in other jurisdictions.47–50 The SA case study can constitute a useful bellwether in trying to understand upcoming challenges, in particular industry interference, in tobacco control policy progress in sub-Saharan Africa. Specifically, a key implication of our study is that the public health community needs to prepare and pre-empt economic arguments about tobacco control policies, including economic studies that counter industry claims, modelling studies of the effectiveness of tobacco control policies and cost-savings to the health system, and accurate data about the number of people employed by the tobacco industry. A second implication is the need for the global tobacco control community and funders to support local tobacco control advocates to successfully access and use media in countering the tobacco industry’s arguments. This is especially important given evidence that tobacco companies provide journalists with a range of incentives,44 51 which likely affects how those journalists frame tobacco issues. Third, continued media monitoring and engagement by the public health community with journalists and editors could ensure greater transparency in media reporting, and greater awareness and exposure of conflicts of interest when reporting on issues of tobacco control. In particular, exposing the sometimes hypocritical nature of tobacco companies’ arguments could be important in driving tobacco industry denormalisation, which is an effective tobacco control intervention.52–55 One such example is the use of illicit trade as an argument against regulation by the same organisations that have been fuelling illicit trade and undermined measures to control it, in SA and globally.56 57 Another is the use of tax-based arguments, given the tobacco industry’s history of global tax evasion and avoidance.58 The detachment between the tobacco industry’s rhetoric and practice is well evidence in the literature,55 59 60 and should be exposed more forcefully if the tobacco control community hopes to challenge the tobacco industry’s use of economic arguments to oppose tobacco control.

Limitations

The identified dominance of economic arguments might be partly attributable to the fact that the analysis included articles that referred both to the Bill, and to the separate tobacco tax regulation. However, because these developments overlapped, and lobbying and arguments around these issues frequently conflated, separating the two would risk mischaracterising the actual picture of the public debate on tobacco control in SA in the analysed period.

This study only reported on English-language articles openly referencing tobacco control and tobacco tax regulation in SA and did not analyse the reach or prominence of the articles (the readership numbers, the word count of articles, what page they appeared on, how much space they occupied, the readership numbers, the political leanings of the newspapers) nor stakeholders’ responses to them.

Finally, this study only focused on newspaper media and did not include other media, such as social media platforms, or radio, which is a medium that is especially well used in SA.61 However, our approach nonetheless enabled an analysis of the range of arguments put forward during the public debate around tobacco control regulation in SA.

Conclusion

The tobacco industry and its allies were able to shape the media debate on tobacco control legislation in SA in 2018 and 2019. Their success in focusing the discussion on economic considerations risks undermining tobacco control progress in the country. Local and international tobacco control advocates, with support of global funders, should seek to build relationships with media ensuring greater transparency in reporting on tobacco control, and build a relevant scientific base to pre-empt, counter, and expose the hypocritical nature of economic arguments advanced by the industry.

What this paper adds

  • Studies conducted in high-income countries have examined how arguments supporting or opposing tobacco control policies have been framed.

  • Tobacco control policy debates dominated by economic framing risk marginalising public health interests and undermining proposed legislation.

  • Few publications have this far focused on how tobacco control policies have been represented by the media in sub-Saharan Africa or other low/middle-income countries.

  • The tobacco industry used the media to promote mostly an economic framing of the proposed tobacco control legislation in South Africa between January 2018 and September 2019.

  • To amplify its message, the tobacco industry launched campaigns to coincide with policy windows, used third parties to advance its rhetoric and recycled anti-regulation campaigns from other countries.

Data availability statement

Data are available upon reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

Research Ethics Approval Committee for Health, University of Bath (reference number: EP 18/19 082).

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Twitter @ZatonskiMateusz

  • Contributors All authors have contributed to the conceptualisation and drafting of this paper. MZZ and LR have conducted the data collection and analysis, and carried out the revisions. MZZ acted as a guarantor for the overall content of this article.

  • Funding This project, and MZZ’s, LR’s, and AG’s time, were funded by Bloomberg Philantropies Stopping Tobacco Organisations and Products project funding (www.bloomberg.org). COE’s time was funded by the South African Medical Research Council.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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