The case against e-cigarettes

E-cigarettes are heavily promoted as a ‘healthy’ alternative to smoking tobacco, but they are potentially just as dangerous. Not only are they a gateway to real smoking, but their apologists make inaccurate claims and attempt to denigrate World Health Organisation research on the issue.

Ivo Vegter in his article “On World No Tobacco Day, the WHO should promote vaping” (Daily Maverick, 14 May 2019) E-cigarettes are battery-operated devices which heat up a liquid to release a vapour that is inhaled. Unlike cigarettes, no smoke enters the lungs but vapour does. A minority of e-cigarettes do not contain nicotine.

Vegter repeats claims that e-cigarettes are 95% safer than cigarettes and that they are a tool that have been designed to help smokers to stop.

The truth is that there is no scientifically accepted evidence that e-cigarettes are 95% safer. Such claims are made by researchers who have direct conflicts of interests and by institutions for whom the promotion of e-cigarettes is of direct financial benefit to their business.

There is considerable evidence that e-cigarettes have introduced new toxic hazards into the act of smoking, and have accentuated the problems associated with nicotine as a toxic agent.

The oft-cited Public Health England (PHE) study that concluded that e-cigarettes are 95% safer than cigarettes was based on a method that used no empirical data, and derived its estimate based on informant opinion. This is not a scientifically accepted method used for informing public health policy when other data are available. Moreover, the researchers were compromised by a conflict of interest due to their ties with the industry. The methods used by PHE have been shown to be fundamentally flawed in a 2015 editorial published in the authoritative medical journal  The Lancet.

Secondly, the claim that e-cigarettes have been designed to help smokers stop is not accurate. Rather, e-cigarettes have emerged to maintain the industry’s market share as the emerging recognition of the health effects of tobacco has seen a reduction in the prevalence of tobacco use. A recent New England Journal of Medicine study found that 80% of users of e-cigarettes, who were using them to stop smoking, were still using e-cigarettes a year later, compared to only 9% of former smokers using conventional nicotine-replacement therapy to stop smoking.

Reviews of other available evidence arrived at similar conclusions and noted also that e-cigarettes do not always help users to stop, but instead are more likely to encourage them to continue to use both cigarettes and e-cigarettes if they are already smokers; or encourage young people to start using e-cigarettes if they are not smoking. Scientific evidence has therefore shown that other cessation methods are far more effective in helping smokers to stop and do not act as a gateway to introduce young people to smoke.

The South African Demographic and Health Survey (SADHS) 2016 reports that 2% of women and 3% of men aged 15+ use e-cigarettes in South Africa. Articles such as Vegter’s continue to spread misinformation to these e-cigarette users and to young people who will be recruited to smoking in future by induction through the use of e-cigarettes.

Additionally, what Vegter does not mention, is that the e-cigarette industry fails to list all the ingredients on the e-cigarette packs, but rather concentrates on the absence of tobacco in the product as translating into safety in their marketing. However, many of the constituents in e-cigarettes are chemicals approved for other uses and their toxicity, especially when used as part of an e-cigarette system, is not fully known.

Heating the e-cigarette liquid to 200^oC has implications for carcinogenesis: e-cigarette liquid contains formaldehyde, which has been classified as “a probable human” carcinogen by the International Agency for Research on Cancer (IARC). IARC has yet to examine the carcinogenic risk of nicotine, but has indicated it has elevated nicotine as a high-priority chemical requiring urgent evaluation for cancer risks.

Moreover, e-cigarettes create new health risks, which are not present with traditional cigarettes. For example, fine and ultrafine particles released in the vapour can more easily be deposited into the deeper parts of the respiratory system than the smoke from cigarettes. This leads to an increased risk of a user developing a cardiovascular disease or non-cancer lung disease. A University of San Francisco study in 2018 reported that daily use of e-cigarettes almost doubled the likelihood of a heart attack.

Professor Anthony Westwood, paediatric and child health specialist at the University of Cape Town, has noted that “there is increasing evidence showing that both nicotine and the aerosols from these products result in harm such as pulmonary inflammation, impaired immunity and reduced lung function”.

Studies have also shown that young people are increasingly progressing to smoke cigarettes after trying out electronic cigarettes. Global evidence suggests e-cigarettes are a gateway to the use of other tobacco products, especially among adolescents. There is an epidemic of e-cigarette use among children at US schools which far exceeds smoking prevalence found in previous studies. Far from helping smokers to stop smoking, e-cigarettes appear to be very effective in recruiting new users to replace adults leaving the smoking population.

Cigarettes were allowed to kill millions of people before they came under the radar of governments and the WHO. It will be a grave error on the part of the WHO to wait to witness all the possible harms e-cigarettes could cause before taking a stand to regulate e-cigarettes.

The Forum of International Respiratory Societies in 2014 issued a position statement which called for more evidence to be made available, and for an analysis of the available evidence to be carried out. They recommended that e-cigarettes be restricted or banned until more information about their safety is available. In 2018, they released a new position statement around e-cigarette use among youth, calling for the regulation of e-cigarettes as tobacco products and their inclusion in smoke-free policies to protect this vulnerable population from e-cigarettes and other nicotine delivery devices.

The short-term health impact of e-cigarettes is already clear. The long-term impact will only be known a decade or more from now, but there is already enough evidence of harm for 98 countries globally to have chosen the path of regulating e-cigarettes.

Deliberate misinformation from the e-cigarette industry and writers like Vegter has led to misperception among many, including some health professionals. This has created confusion for the public and e-cigarette users who are now uncertain about the risks and perceived benefits of smoking e-cigarettes.

It is imperative that e-cigarettes be regulated in South Africa as soon as possible to counteract this confusion, so we welcome the inclusion of e-cigarettes, and the comprehensive proposals for their regulation, in the Draft Control of Tobacco Products and Electronic Delivery Systems Bill. The Bill – and the WHO Framework Convention on Tobacco Control – is evidence-based. The tobacco industry and its apologists are trying to derail it by denigrating WHO and making inaccurate claims. Every piece of tobacco legislation in South Africa has been vehemently opposed by the cigarette manufacturers, and yet the evidence shows it has worked because prevalence has dropped. At the same time, the tobacco control laws have been upheld by the courts and supported by the public.

We urge the Department of Health to prioritise this Bill and ensure that it becomes law within the next year.

The writers are members of the Tobacco Control Advocacy Alliance and represent the following organisations: National Council Against Smoking, University of Cape Town, University of Western Cape, South African Medical Research Council, Chronic Disease Initiative for Africa.