When the vapour dissipates - what do we really know about e-cigarettes?
The electronic cigarette and tobacco industries may be using dodgy, old data about the safety of e-cigarettes in public pleas for kinder regulation.
E-cigarettes are devices that allow users to inhale solutions that usually contain nicotine in a colourless liquid such as propylene glycol - an additive typically found in food and cosmetics, the United States Centres for Disease Control explain. This solution is heated in the hand-held machines and produces a vapour, which is why smoking e-cigarettes is sometimes called "vaping".
The national health department's new tobacco control Bill proposes stiff regulation for e-cigarettes and their traditional counter-parts, including advertising restrictions, plain packaging and public smoking bans.
Since the Bill's July release, the Vapour Products Association (VPA), which represents e-cigarette manufacturers and retailers, has publicly claimed that e-cigarettes are 95% safer than conventional cigarettes and may even help traditional smokers to quit. Strict regulation of vaping, it argues, risks robbing citizens of the opportunity to access a safer alternative to tobacco cigarettes or a smoking cessation tool. These calls have been backed by the industry-funded Tobacco Institute of Southern Africa.
But the research behind the claims is mixed, and some warn that it's too early to claim that vaping is safer than smoking or that it could help smokers to kick the habit.
E-cigarettes may be less harmful than tobacco, but local experts warn there is not enough evidence to warrant separate regulation. (Reuters)
For decades, public health experts and the tobacco lobby have faced off over the industry's use of bad science to support claims that their products were safer than they were.
For instance, a 2001 review of leaked industry documents published in the American Journal of Public Health showed how tobacco companies set up a non-profit organisation in 1988 to fund scientific research that would contradict the link between second-hand smoke and cancer.
But now, a third group championing "harm reduction" has emerged from somewhere in between. Harm reduction refers to ways that people try to mitigate the dangers or harms associated with a particular act. For instance, giving people who inject drugs access to clean needles is a harm reduction strategy because it reduces the HIV and hepatitis C risk associated with drug use given the possibility of sharing needles.
Some scientists are arguing that, just as clean needles help drug users to avoid infections, vaping can help cigarette smokers to steer clear of health risks such as cancer by reducing how much they smoke.
Last week, more than 70 nicotine specialists appealed to the World Health Organisation (WHO) to include vaping as a recommended harm reduction method in the WHO's tobacco control guidelines.
But research into vaping's harm reduction potential and safety is mixed and controversial.
In 2015, the British government agency Public Health England (PHE) published a controversial review of almost 100 studies and reports that claimed e-cigarettes were 95% safer than tobacco cigarettes.
The figure came from only one paper in which an expert panel rated 12 nicotine products including pipes, cigars and nicotine patches over two days based on how harmful they were. But the committee also admitted that it lacked hard evidence about most products under its review - a fact that an editorial of the editors at The Lancet medical journal later pointed out the PHE's study failed to mention.
The publication also raised questions about possible conflicts of interest because some authors of the studies cited in PHE's work had links to the tobacco industry.
In a written response to The Lancet, the lead researcher of the disputed paper, Imperial College London's Professor David Nutt, hit back by arguing that someone with bias "could not have had any meaningful influence".
Nutt's co-author was Kgosi Letlape, the former South African Medical Association chairperson and current president of the Health Professions Council of South Africa. Letlape told Bhekisisa that arguments about conflicts of interest are irrelevant.
Instead, he says, detractors should focus on replicating the panel's results. "You refute science by coming out with your own results. None of this has been done. You don't just express an opinion from thin air."
Letlape cofounded the African Harm Reduction Alliance with Delon Human. EuroSwiss Health, Human's health consulting company, partly funded Nutt's 2014 study.
Human admits to having links to the tobacco industry.
"The reality is my company has done harm reduction work for the alcohol, food and tobacco industries. Our aim is to help eliminate smoking of combustibles [conventional cigarettes] - that refutes any argument that this is an industry mouthpiece."
But most tobacco companies also sell e-cigarettes, South African Medical Research Council specialist scientist Catherine Egbe says. Egbe works with the council's Alcohol, Tobacco and Other Drug Research Unit.
She believes the review is not only a "disservice to public health" but is now also outdated after several studies - including 2015 research in the Journal of the American Medical Association - showed that e-cigarettes make young people more likely to use tobacco cigarettes too.
Even when scientists used the "optimistic" assumption that e-cigarettes were 95% less harmful than tobacco cigarettes, a 2018 modelling study in the journal PlosOne found that vaping was overall more harmful than beneficial for population health.
In fact, they found e-cigarette use in 2014 would lead to about 1.6-million years of life lost in the US alone. Egbe explains: "If the industry is so concerned about their customers, they should reduce the amount of nicotine in cigarettes."
Even if vaping is safer than tobacco, a 2018 study has found the habit could cost over 1.6-million years of lives lost in the US alone. (Reuters)
Today, the United Kingdom's health department actively promotes e-cigarettes as a way to stop smoking. PHE also continues to defend its statistics in an evidence update released in 2018.
South Africa's tobacco and vaping lobbies have lauded the UK's regulations for e-cigarettes as among the most progressive in the world.
Meanwhile, VPA has launched a social media campaign called Save Vaping based on this information and has garnered over 10 000 public comments and anecdotes - both positive and negative. The inputs, along with a compilation of the "latest scientific research on vaping", were sent to the health department in response to its new Bill, VPA chief executive Zodwa Velleman says.
"Our message is that you should be able to choose something safer. We're not saying e-cigarettes are a magical product, but it is an alternative."
She also warns that the Bill may not only restrict access to vaping but also spawn unsafe counterfeits with its demand for plain or unbranded packaging.
Although South Africa will become the first country to impose plain packaging for e-cigarettes, countries such as Canada, France and Australia have enforced this type of packaging for tobacco cigarettes.
A year after Australia implemented the rule, a 2014 study published in the British Medical Journal found no evidence that the packaging was linked to an increase in illegal products.
Both VPA and the African Harm Reduction Alliance say they remain confident in PHE's conclusion that e-cigarettes are at least 20 times safer than traditional cigarettes.
Tisa did not respond to Bhekisisa's questions about allegations that the data it bases its arguments on, is old. Chief executive Francois van der Merwe did however point out that "e-cigarettes are a minuscule portion of my members' business". In an interview with Bhekisisa in September, he reiterated his support for Nutt's 95% figure and the role electronic cigarettes could play in smoking cessation.
Have you seen the tobacco industry's #TakeBackTheTax campaign? Read about it here.
Richard van Zyl-Smit is the head of the University of Cape Town's Lung Clinical Research Unit. He says that, although the methodology of Nutt's was reasonably sound, more confirmatory research is needed before it can be used to back policy change.
Van Zyl-Smit doesn't doubt that vaping is safer than smoking, although he warns that the difference in safety levels may still not be enough to warrant separate regulation.
Tobacco cigarettes kill half of the people who use them, the WHO estimates.
"If e-cigarettes killed 40% of the people who used them, they would already be safer," he says.
"E-cigarettes need to be no more dangerous than fresh air to be a consumer product for non-smokers. Otherwise, they just remain as an expensive way to maintain an addiction."
Meanwhile, the UK's lax vaping laws and its position on e-cigarettes as a harm reduction tool may not be going as well as the tobacco industry had hoped.
When British scientists analysed population surveys ranging from 2006 to 2016, they found no evidence that e-cigarettes or nicotine replacement therapy medicines such as patches or gum had an impact on how much people smoke. The research was published in the British Medical Journal this year.
In South Africa, the newly proposed Bill will put the country in line with WHO recommendations for tobacco and nicotine control.
The University of Cape Town's economics of tobacco control project researcher Zunda Chisa says it also reflects the available evidence on vaping's harms and benefits.
Strong opposition to regulation is nothing new, says Van Zyl-Smit.
"We've seen this show before with tobacco - now with more money and more personalities ... [but] more is at stake if we allow history to repeat itself."