Legislative limbo on e-cigarettes must end to close the information gap on health risks
A survey of South African e-cigarette users has found that conversion to traditional cigarette use had occurred in some people who had no prior history of smoking – but it also found a number of people had quit smoking through vaping. The regulation of e-cigarettes must be implemented urgently, with clear communication of the health risks inherent in their use.
In the 20 years since the first e-cigarette was invented, it has become relatively commonplace to encounter a marshmallow-scented plume of vapour on a daily runaround.
E-cigarette use has become popular globally; a recent study that looked at usage on four continents found that regular e-cigarette prevalence is around 11%, with prevalence higher among men than women. The study covered North America, Asia, Europe and Australia/Oceania, finding current vaping prevalence in these regions at 10%, 14%, 11% and 6%, respectively.
The vaping industry has evolved to offer a huge variety of products such as cig-a-likes, vape “pens”, box-sets and disposables. E-liquid flavours range from tobacco (aromatic, rich), fruit (zesty lemon, watermelon chill), menthol (refreshing mint), dessert (unicorn jam, custard surprise) to many others (coffees, bakery, and so on).
There is still much controversy around the product.
Observers fall into two major camps. In one camp, e-cigarettes are viewed as a lifesaving alternative for cigarette smokers trapped in deadly tobacco addiction. This argument posits that, compared with regular cigarettes, e-cigarettes are a less harmful way to deliver nicotine.
In the other camp, e-cigarettes are viewed as a dangerous gateway to tobacco for impressionable youths who might never have picked up the antiquated, offensive and socially unacceptable cigarette.
Opponents of e-cigarettes argue that they are specifically designed to entice young people to purchase them, given their exotic flavours and “hi-tech” feel.
Sceptics reiterate that, for non-cigarette smokers, vaping introduces harm to health, and e-cigarettes have been used to deliver other drugs such as forms of THC (the psychoactive component of marijuana), methamphetamine and others.
This divergence in thinking is also evident in how policymakers handle e-cigarettes globally. Some countries, like the United Kingdom, are banking on e-cigarettes being a tobacco-quitting aid, going so far as to freely distribute e-cigarettes to smokers. At the other extreme are countries that are taking a cautious approach, such as Australia, which recently banned the import of vapes.
To date, South Africa has been slow in its policy response to e-cigarettes.
The comprehensive Control of Tobacco Products and Electronic Delivery Systems Bill intends to regulate e-cigarettes as tobacco products, including prohibiting their use in all enclosed public places, workplaces and enclosed spaces where children are present.
However, the bill has been stuck in a legislative no man’s land since 2018 and is yet to be enacted. An excise tax on e-cigarettes was only implemented on 1 June 2023, at a rate of R2.90/ml of e-liquid.
In an effort to shed light on e-cigarette use in South Africa, the Development Gateway and the Research Unit on the Economics of Excisable Products conducted an e-cigarette survey in 2022 as part of the Tobacco Control Data Initiative.
The data are representative of adults (18 and older) living in urban South Africa (including metro and non-metro areas). Telephone interviews were conducted with 21,263 respondents, asking about their use of e-cigarettes and conventional cigarettes.
Among urban South African adults, 5.8% had experimented with e-cigarettes, 4% were current regular users at the time of the survey, and 1.5% were quitters. This equates to a total of 11.3% who had a history of e-cigarette use.
Regular e-cigarette use was highest among coloured people (8.3%), white people (7.7%) and Indians/Asian people (6.7%), and lowest among black people (2.7%). Males (5.4%) had a higher prevalence than females (2.6%). People living in middle- and high-income areas (5% and 6%, respectively) were more likely to vape than people living in low-income areas (3.1%).
There were more young e-cigarette users in urban South Africa than older users. Prevalence in the 18 to 34 age group was substantially higher than in older groups, at between 6.2% and 7.7% (compared with between 1.5% and 3.7% for older groups). The median age that e-cigarette users tried their first vape was 26, and the median age that they started regularly using them was 28. Of current e-cigarette users, 33% had never been cigarette smokers.
Cigarette and e-cigarette users were grouped by the sequence in which respondents used each product. Of the vapers who had never smoked cigarettes before starting vaping, 19% later started cigarette smoking and 88% of these were still cigarette smokers at the time of the survey. The vapers who had not taken up cigarette smoking at the time of the survey (81%) were at risk of starting smoking later. For the group that had started smoking cigarettes, vaping likely played a role in their smoking initiation.
On the flip side, we looked at people for whom vaping may have played a role in cigarette quitting. Of people who smoked cigarettes, 17.3% were first cigarette smokers who later started vaping, and of these, 13% quit cigarette smoking. Of this group, 35% had also quit vaping at the time of the interview.
Ultimately, the data provide evidence that e-cigarettes are sometimes used as a cigarette-quitting device, but that vaping could also have led to cigarette uptake that might never have happened in the absence of e-cigarettes.
Vapers who have never been cigarette smokers are exposed to the health risks of vaping and may in future take up cigarette smoking.
Given this, the government should regulate e-cigarettes in a way that communicates their potential harm. The bill on e-cigarettes should be passed with haste. DM
Kirsten van der Zee is a research officer at the Research Unit on the Economics of Excisable Products at the University of Cape Town.