New South African studies support urgent need to regulate e-cigarettes

Research on e-cigarettes conducted by prominent public health researchers has emphasised the need to speedily pass the Control of Tobacco and Electronic Delivery Systems Bill (2018) into law. Two years have passed since the Bill closed for public comments in August 2018, during which time the e-cigarette industry, currently largely unregulated, has further taken hold in South Africa.

Professor Lekan Ayo-Yusuf, director of the Africa Centre for Tobacco Industry Monitoring and Policy Research (ATIM) at the Sefako Makgatho Health Sciences University (SMU), says the research results support an urgent need for a regulated environment in order to better protect our youth from the health harms of e-cigarette addiction. “While the tobacco and e-cigarette industry likes to position e-cigarettes as cessation aids, the limited effectiveness of these products for long-term quitting, the health harms associated with usage and the industry’s clear and targeted marketing to youth are facts which are conveniently omitted from their narrative. This series of studies provide very useful information to guide policy makers in South Africa.”

The series of recently published studies, conducted by the ATIM at SMU, the University of Pretoria and the South African Medical Research Council (SAMRC) assessed local e-cigarette use, evaluated the effectiveness of e-cigarettes as cessation aids, and analysed the costs of e-cigarette usage using multiple data sources, including two large population-level surveys. Finally, geospatial mapping was used to understand the distribution of vape shops across South Africa and how this may impact youth usage.

A key finding from one of the prevalence studies was the substantial prevalence of e-cigarette use by South Africans older than 16 years. Overall, 2.71% of adults, translating to 1,09 million people, used e-cigarettes daily or occasionally during 2018. Majority of current e-cigarette users (97.5%) were concurrently regularly smoking cigarettes.

The study on cessation concludes that any presumed benefits of e-cigarettes on cessation may be partly attributable to pharmacotherapy and counselling, given the concurrent use of e-cigarettes with these evidence-backed cessation aids among past quit attempters using e-cigarettes. Among current combustible tobacco smokers who attempted to quit in the past, current e-cigarette users were more likely than ‘never’ e-cigarette users to have used other cessation aids.

In another study, for ‘ever established’ smokers of combustible tobacco products who had tried to quit, e-cigarette use was associated with higher likelihood of short-term, but not long-term quitting. The study in fact also indicated a higher likelihood of smoking relapse among ‘ever’ smokers in South Africa who had tried to quit using e-cigarettes. The likelihood of long-term quitting lasting 6-12 months was 80% lower among those who used e-cigarettes once-off/rarely, 70% lower former e-cigarette users, and 77% lower among regular e-cigarette users compared to never users. Despite this evidence of limited effect on cessation, our study found that among current combustible tobacco smokers, many more ‘ever’ as compared to ‘never’ e-cigarette users were convinced that e-cigarettes could assist smokers completely quit (35.5% vs. 20.4%) or cut down (51.7% vs. 26.5%). This dominant belief among those who had ever tried e-cigarette is likely a result of the manufacturers’ marketing of these products as cessation aids, despite not having scientifically tested them as such in South Africa or in similar poor-resource settings.

The cost study revealed that, contrary to claims made by e-cigarette manufacturers, using e-cigarettes is more expensive than smoking cigarettes when comparing daily users of both products over a one-year period. Annual cost associated with daily use was R6,693 for manufactured cigarettes and up to R19,780.83 for e-cigarettes. Findings from this study show that implementing excise taxes on e-cigarettes at 75% of the cigarette excise tax rate could generate annual revenue of up to R2.20 billion. “Untaxed for more than a decade in South Africa, e-cigarettes will only be taxed from this year, at a rate of 75% of the tax on tobacco. This will likely reduce initiation by youth and provide additional revenue to cover the health and economic harms they cause while contributing to funding the National Health Insurance” says Dr. Catherine Egbe of SAMRC.

The final study found that of the at least 240 vape shops in South Africa, 39% are within a 10km radius of a University or college campus, and 65.3% are within a 20km radius of a University or college campus. “We found that living near a vape shop was associated with using an e-cigarette in the past or currently,” says Dr. Israel Agaku of the University of Pretoria. “These important findings justify the regulation of lifestyle advertising targeted at the youth and the limitation of access to these products by children.”

The researchers conclude that there is need for the regulation of e-cigarette design, manufacture and marketing in South Africa and further call for immediate action while awaiting the passage of the Tobacco Control Bill. “Several issues identified can be acted upon now by key stakeholders, including clinicians, the media, parents, academics, corporations, youth organizations, non-governmental organizations, and local governments,” says Professor Ayo-Yusuf of ATIM.

Professor Ayo-Yusuf says that advocacy groups and researchers can maintain vigilance in relation to the tobacco industry, to identify and publicize any evasive or deceptive marketing. Clinicians can educate themselves and their patients about the latest evidence regarding e-cigarettes, and recommend evidence-based products as smoking cessation aids for both cigarette and e-cigarette users. Pharmacies can voluntarily remove e-cigarettes from their shelves as a health promotion initiative. Parents and caregivers can adopt voluntary smoke-free home and car rules that prohibit all forms of tobacco and e-cigarette use.

“Globally, research on these relatively new products is guiding better regulation, and we trust that South Africa will implement the Tobacco Control Bill as a comprehensive, evidence-based policy,” Ayo-Yusuf concludes. “We all have a responsibility to remain aware and vigilant in protecting the health of our people.”