Dressed for the chilly weather, 43-year-old Muntu Mbanjwa, a presenter at the Alex FM community radio station in Alexandra township, sits down at an outside table of a Rosebank coffee shop in Johannesburg. He immediately reaches into his right trouser pocket for his packet of cigarettes and quickly lights up.
"I've tried to quit several times but it's difficult," he says, briefly resting his arm on the table, cigarette in hand. The tips of his thumb, index and middle fingers are stained an orange yellow from decades of smoking. "I always go back to smoking within a few weeks because all these health problems I hear about have not affected me yet – maybe at a later stage."
According to Robert Anthenelli, an international substance abuse expert from the University of California: "Cigarette smoking is the number-one preventable cause of death in the world."
He said most people who smoke are aware the habit can lead to serious health complications – including lung cancer, heart diseases and strokes – yet very few manage to quit.
"Nicotine, found in cigarettes, is addictive. They have this addiction and it becomes a part of them." According to the World Health Organisation (WHO), nicotine can be as addictive as heroin and cocaine.
Even though it is the nicotine that is addictive, according to Anthenelli, it is the tobacco, which contains thousands of "toxic" chemicals, that is responsible for causing smoking-related health ailments.
Anthenelli says that whenever a smoker quits they experience withdrawal: "They start to feel lousy, nauseous, develop a headache, their mood might get low, they become anxious and their thinking may slow down. When someone is going through this kind of withdrawal the first thing they think about is having another cigarette."
He says that is the main reason why smokers relapse.
Mbanjwa started smoking cigarettes at the age of 15 because of pressure from older friends at his school. He has tried and failed to quit every year – and now it's nearly 30 years later.
"One week will go, two weeks will go, but come the third week – no man, it's too much," he shakes his head in frustration. "I feel like something is missing and I need to go back and smoke. I need that comfort."
He says smoking a cigarette makes him "feel good inside".
And soon he will need to light up yet again. "If I don't smoke for the next three to four hours, I start to feel cravings."
Yussuf Saloojee from the National Council against Smoking says nicotine affects the pleasure centres in the brain. "It releases dopamine, which is the same substance released after eating or having sex."
He says this is the initial reaction when someone begins to smoke tobacco, but it is not maintained. "Over time smoking stops producing pleasure. It does the opposite – it causes stress."
According to Saloojee, the addiction takes over and the "good" or "satisfied" feeling a smoker gets while smoking a cigarette is from allaying the withdrawal symptoms.
"A recent study looking at smokers and ex-smokers showed that, after three to six months of quitting, ex-smokers experienced significantly lower levels of stress – the stress is actually caused by a lack of nicotine in the body."
The latest National Health and Nutrition Examination survey conducted by the Human Sciences Research Council, published last year, showed that 16.4% of South Africa's adult population smoke tobacco.
"In 1994 this figure was double. Almost one in three adult South Africans were smokers," says Saloojee.
He attributes this decrease to tobacco legislation including high taxes placed on cigarettes as well as restrictions on smoking in public places. Finance Minister Pravin Gordhan recently announced in his budget speech that there would be further increases in taxes on cigarettes, of 59c a packet.
But, Saloojee says, cigarettes still kill an estimated 120 South Africans every day. According to the WHO, tobacco kills more than five million people around the world every year – almost three-quarters of tobacco-related deaths are caused by lung cancer.
Tried and failed to quit
The survey also showed that, among current smokers in South Africa, 48.1% had tried and failed to quit in the past year.
"Ninety percent of smokers who quit successfully do so on their own, but there are a number of strategies designed to help, including nicotine replacement therapies (NRTs) and medication,"' says Saloojee.
According to a 2013 article published in the South African Medical Journal (SAMJ), the most effective aid to stop smoking is a medication called Verenicline, which is marketed under the trade name Champix and has to be prescribed by a doctor.
One pill is taken twice a day for 12 weeks. It reduces withdrawal symptoms and stimulates the release of dopamine. A third of smokers who use this, according to the article, had not relapsed in the year after quitting.
But Saloojee cautions: "People with risk factors like depression or suicidal thoughts should be careful when taking Champix as these can be exacerbated. So this medication should only be taken under medical supervision."
An antidepressant called bupropion has been found to help smokers to quit but is slightly less effective than Champix, according to Saloojee. It is marketed under the name Zyban and also has to be prescribed by a doctor.
NRTs, which relieve withdrawal symptoms because they release nicotine into the body, have a one-year success rate of about 20%. Saloojee says that a combination of more than one type of NRT can increase the chance of success. These are available as nasal and mouth sprays, inhalers, tablets or chewing gum. They can be bought over the counter at pharmacies. But according to the SAMJ article, factors other than addiction, such as mental wellbeing, can influence whether a smoker successfully quits.
Mbanjwa agrees: "We are living in a stressful world. Every year I try to quit but the moment I get depressed I start all over again."
Anthenelli says the association between smoking and depression is not fully understood, but people with mental illness in the United States "are smoking in much higher rates than those without – about two to four times of the general population".
He says that in the US about half of the cigarettes in the country are smoked by patients with psychiatric and substance use disorders. Although there are no statistics about the correlation between tobacco use and mental illness for South Africa, he says the trend is probably true all over the world.
According to Anthenelli, if someone is depressed "it's not the right time to quit smoking".
He suggests emotional smokers should avoid stressful situations as much as possible and find other ways to deal with stress, such as deep breathing.
"It's better to try treating the depression and to become mentally stable before trying to quit smoking."
Saloojee says that another phenomenon, which he terms "sedative smoking", prompts ex-smokers to relapse.
"Women in particular use smoking as an emotional crutch – when they are stressed or emotional they turn to cigarettes to help them calm down."
Two cups of coffee and three cigarettes into his meeting at the Rosebank coffee shop, Mbanjwa announces that he wants to quit for good one day, but he has not tried any medication or NRTs.
"I know if I quit it will be like I'm living in another world without smoking. My skin will even begin to glow."
He looks through his orange-tinted glasses and folds his arms.
"But if you smoke or not," he pauses, tilts his head and smiles, baring two front teeth stained brown near the bottom, "when you die, the funeral parlour will charge the same price."
Ramatamo Sehoai is a Bhekisisa fellow