A recent study showing teenagers who use e-cigarettes are three times more likely to smoke normal cigarettes than those who don't amplifies the South African government's calls to regulate e-cigarettes.
The study highlights the potential harm of e-cigarettes - or electronic cigarettes. These are the battery powered, pen-shaped devices delivering nicotine in a vapour instead of smoke which have taken the world by storm. It is also in contrast with other research that suggested e-cigarettes can reduce the harm of smoking if an individual uses them as a substitute.
The study comes months after South African Health Minister Aaron Motsoaledi announced his intentions to regulate the use of e-cigarettes.
Globally, the regulation of e-cigarettes remains controversial. While some countries such as Brazil, Singapore and Switzerland have banned it, others like France and Canada have regulated it as a tobacco product. Some countries have regulated them as medicines because they are devices that deliver nicotine.
In South Africa e-cigarettes that contain nicotine are currently regulated under the Medicines and Related Substances Act as a schedule three substance. This means they can only be prescribed by a doctor and only be sold at a pharmacy.
But given the availability of these products in non-pharmaceutical retail outlets across the country, the level of enforcement of the current regulation remains questionable.
There are just under 200 000 e-cigarette users in South Africa. E-cigarettes have become fashionable among the country's young adults. Sold at kiosks in malls, they come in different flavours that make them attractive to the youth. Some are marketed as healthy 'herbal' flavours. These numbers are likely to rise unless action is taken by the government to further regulate the devices' use.
Weighing up the pros and the cons
Experts estimate that e-cigarettes are 95% safer than traditional cigarette smoking. They have significantly reduced toxicant levels. This means they could potentially reduce the harm that comes with smoking combustible tobacco products such as cigarettes. This could help some smokers to quit. But others who cannot or do not want to stop smoking could switch to e-cigarettes to reduce smoking-related diseases and death.
In South Africa, smoking causes about 45000 deaths annually.
A lack of regulation around e-cigarettes means that these products can potentially contain toxic chemicals. There are compounds in e-cigarettes which might ordinarily not be toxic but when delivered into the lungs during "vaping" might cause an as-yet unknown adverse effect.
Recent research published in the New England Journal of Medicine suggests e-cigarettes which operate at high voltages emit significantly higher levels of cancer-causing formaldehyde than a burning cigarette.
Another study suggests the metal wick that is designed to heat up the e-liquid might actually release cancer-causing metals) such as cadmium into the vapour, which is delivered into the lungs.
A separate study has demonstrated that e-cigarette vapour may increase susceptibility to respiratory infection, especially in young children.
Electronic cigarettes might also have addiction-boosting compounds other than nicotine increasing their abuse liability. This is according to another study published in the American Chemical Society's journal, Chemical Research in Toxicology.
Why we need to regulate e-cigarettes
Should e-cigarettes not be regulated under the Tobacco Products Act, as is currently the case, South Africa could erode the gains from the current ban of cigarette advertisements and promotion. This would happen through brand-sharing with traditional cigarettes along with large adverts and promoting these brands.
Potentially there are two negative effects. South Africa could be creating an environment where cigarette brands are once again glamourised and smoking is re-normalised. But it also could encourage young people to smoke and promote the fashionable use of e-cigarettes.
The widespread availability of e-cigarettes may also encourage those who would have ordinarily quit smoking to keep puffing. They now have the opportunity to smoke these e-cigarettes in places where ordinary cigarettes have been banned.
The passive exposure to e-cigarette vaping has recently been shown to evoke the urge to smoke actual cigarettes. This finding supports the call by the UK to ban e-cigarette smoking in public places as this would contribute to reducing cues for smoking for those trying to quit cigarette smoking.
This, taken with the risk for accidental ingestion of e-liquid by an infant, makes it critical that regulatory intervention requires e-liquids to be in childproof packaging.
A way forward
The emerging evidence supports the regulation of e-cigarettes in South Africa, whether they contains nicotine or not.
The current scientific evidence to support the use of e-cigarettes as an effective mechanism to help smokers to quit is weak. But a regulatory approach should recognise the potential of these devices for the individual smoker who might want to use them to quit cigarette smoking all together.
The South African government would be wise to take action now before the use of e-cigarettes reaches epidemic proportions and their use reverses the gains of several decades of tobacco control.
Prof Lekan Ayo-Yusuf receives funding from the South African National Research Foundation (NRF) and the USAID. He is also affiliated with the Harvard School of Public Health and the School of Health Systems and Public Health at the University of Pretoria as an Extraordinary Professor.