Public Health Scientist & Specialist in Tobacco Control
Alcohol, Tobacco and Other Drug Research Unit
South African Medical Research Council
via email

25 October 2022

Dear Dr Egbe,

Re: An Open Letter: SA smokers looking to quit will suffer if Parliament passes baseless regulations

By way of introduction, my name is Kurt Yeo, co-founder of the consumer advocacy group Vaping Saved My Life (VSML). I am a father, husband, ex-smoker of 20 years, and like millions around the world, a victim of the suffering left in the wake of smoking. The void left behind through the passing of my parents, and the realisation that my family is not unique in this suffering became the driving force behind VSML.

Based on the lived experience of millions around the world, VSML promotes tobacco harm reduction (through the use of electronic nicotine delivery systems, ENDS) for smokers who are unable or unwilling to quit. There is a growing pool of scientific evidence to support our view that something like vaping is less harmful than traditional cigarettes and is an effective way to support smokers seeking less risky alternatives.

As you know, Cabinet has approved the submission of the Tobacco Products and Electronic Nicotine Delivery Systems Control Bill of 2018 to Parliament. There are several points in this new Bill that we at Vaping Saved My Life agree on. Among others, we agree that ENDS need to be regulated and that they should absolutely not be accessible to minors.

However, the way in which the Bill seeks to regulate ENDS will stop smokers from accessing information and guidance on less risky products, which in effect is denying them access to potentially life-saving tools.

I write to you because I am concerned about the way in which you have portrayed some of the science behind vaping in recent public interviews and on your blog. As a Specialist Scientist at the Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council (SAMRC), I am concerned that you are selective in which science you choose to look at and are mis-informing the public of the full debate happening in the scientific community around tobacco harm reduction.

In a country where smoking is the leading cause of death and disease[1] and the options and/or services offered by the public health system to help smokers quit are severely limited, these regulations need to be rethought. Moreover, regulations need to take scientific evidence from around the world into account, in addition to the South African context. It seems unconscionable to me that, while admitting the harm caused by traditional smoking, scientists such as yourself do not seem to want any alternative to be available to smokers who cannot quit through “approved” methods.

I recently read your article entitled ‘Ten reasons why electronic cigarettes need to be regulated in South Africa’ and would like to respond to some of the points you raised where I believe that facts based on extensive scientific research were omitted in your argument.

E-cigarette cessation efficacy and affordability ignored

In your point labelled ‘unproven claims of cessation efficacy of e-cigarettes are harmful to public health’, you essentially deny the existence of studies conducted in many countries around the world, especially the United Kingdom and New Zealand, which prove that vaping is positively associated with quitting smoking successfully. The cessation efficacy of vaping products has been proven by the largest study of electronic cigarettes to date, ‘Nicotine Vaping in England’, which was originally commissioned by Public Health England in 2015 with evidence updates published annually, the eighth and most recent by England’s Office for Health Improvement Disparities (OHID)[2].


Smoking vs E-Cig New Zealand 20/21

If this, and other supporting evidence, is being ignored or overlooked by bodies like the SAMRC and the National Department of Health (NDoH), this is extremely concerning since it effectively robs smokers of a viable way to quit.

You and fellow tobacco control advocates tend to double down by quoting a South African study that you co-authored in 2020 that highlights the high relapse numbers of e-cigarette users back to smoking at the 12-month mark[3]. Unfortunately, a caveat found in the study – which is never shared when the study is quoted – effectively states that 65.5% of those who had used e-cigarettes (compared to 51.9% of those who hadn’t) reported that e-cigarettes were too expensive to use, suggesting that the cumulative costs (devices, vaping liquids and other inputs) associated with vaping may be contributing to smokers switching back to cheaper-priced cigarettes, to access nicotine.

This suggests that e-cigarette cessation efficacy is subject to affordability[4] and would be far higher and more in-line with what has been published by the Cochrane Systematic Review, which, after considering 61 studies, found that e-cigarettes are 1.8 times more effective than other cessation interventions[5]. So convinced of this is England’s Department of Health & Social Care that discussions are being held around having these products prescribed by the National Health Service (NHS) to assist smokers in poorer communities. Similarly, New Zealand Ministry of Health has not only created a website[6] informing their citizens on the facts about vaping but encourages smokers to switch to these less harm products. This strategy and the importance of assisting smokers was clearly expressed by New Zealand Prime Minister Jacinda Arden in a December 2021 press conference[7].

In the South African context, surely the most accurate way to measure the efficacy of vaping would be to run a longitudinal study where this and other methods are provided for free and monitored frequently? Alternatively, a more efficient and less expensive way to establish the efficacy and harm related to these products is to engage with both the UK and New Zealand health authorities and establish why they have such a contrasting view.

The prescription approach is a pain

Unfortunately, your statement that, “…if e-cigarettes are a cessation aid or medicine, they need approval and must be sold under a prescription,” would not work in South Africa. We don’t push products like alcohol-free beer, sugar-free drinks or low-fat yogurt which reduce contents linked to unwanted health effects through a medical approval board, so why should we do this for vaping?

But, more importantly, forcing smokers and vapers through a costly and time-consuming process to practice harm reduction is a bewildering concept, especially if you consider that the deadlier alternative (cigarettes) is available almost everywhere.

The prescription approach is being enforced in more developed countries like Australia. However, with reports of ex-smokers, now vapers, relapsing due to the difficulty of getting a prescription and a growing illicit trade with all the unwanted elements attached, this strategy has failed[8].

My suggested solution would be to license retail outlets and establish manufacturing standards, in addition to active monitoring and enforcement.

Harm reduction, not harm-free

In your article you asserted that, “…e-cigarette use is harmful to human health; any harmful product cannot be left to be freely marketed as a safe product.” Nowhere has vaping been promoted as safe. Groups aligned with tobacco harm reduction have gone to great lengths to highlight that these products offer a degree of risk but are significantly less harmful than combustible tobacco products and should only be used by smokers wishing to quit or reduce the harm associated with combustible tobacco.

However, one of the main findings of the Nicotine Vaping in England study[9] is that there is significantly lower exposure to harmful substances from vaping compared with smoking, as shown by biomarkers associated with the risk of cancer, respiratory and cardiovascular conditions. The study also found that there is no significant increase of toxicant biomarkers after short-term second-hand exposure to vaping among people who do not smoke or vape. Similar results have been echoed in other research such as the 2018 report on Public Health Consequences of E-cigarettes[10] released by the US National Academies of Science, Engineering & Medicine. Strengthening this point, a secondary analysis of a Cochrane systematic review (as you know, widely considered a gold standard in medical research) concluded that switching from smoking to vaping or dual use reduces levels of biomarkers of potential harm significantly[11].

Vaping falls into the category of harm reduction much like seatbelts in a car, crash helmets for motorcyclists and even parachutes for skydiving. These products are not aimed at eliminating harm but are designed to reduce the likelihood of serious injury or death. For decades, science has known that almost all of the harm related to smoking was the burning of tobacco leaf and not the nicotine. Vaping eliminates that and therefore provides a safer alternative.

Accurate reporting required for the real measure of youth vaping

This said, I share your concern for youth vaping. However, the evidence for this is lacking seeing that the first and only Global Adult Tobacco Survey for South Africa does not reflect the number of under 18s who vape[12]. The survey groups young people between the ages of 15 and 24 years, which doesn’t categorise these individuals as per the legal definition of ‘smoking age’ in accordance with South African law[13]. The research must consider the legal definition and whether these individuals started their nicotine habit through smoking or vaping. It also needs to be noted that South Africa has failed to monitor youth smoking, as the last Global Youth Tobacco Survey conducted was in 2011. Any assertions need to be backed by consistent and accurate data.

It has also been said that the biggest issue around youth vaping is that it might act as a gateway to smoking. If this were the case, I would be just as concerned as you are. However, evidence from University College London has ruled this out[14]. Additionally, following the youth vaping trends in the USA utilising the annual CDC National Youth Tobacco Survey[15]. Youth vaping prevalence has dropped by a staggering 50% since its all-time high of 2019, whilst reporting the lowest recorded youth smoking rate at 1.9% in 2021. Having many experts in the field suggesting that youth vaping was for the most part purely experimental and fears of a gateway effect is not supported by empirical evidence. Instead, studies have found is that young people who try e-cigarettes are more prone to risk-taking than kids who don’t vape, so the former may surely be more likely to have a history of experimenting or using traditional cigarettes anyway[16]?

By simply reviewing recent headlines relating to all the risky behaviours involving the youth – alcoholism, drug abuse, and youth pregnancy rates, to mention but a few – it is clear that a far bigger conversation around youth behaviour is needed, instead of purely reporting on symptoms and implementing “whack-a-mole” legislation.

The Bill rightly aims to reduce the incidence of tobacco-related illness, disability and death. Surely the regulations, and those arguing for their enforcement, should draw on all available research and consider the local context if South Africa’s smokers are to truly be helped?

This is a subject I am passionate about. If you would like to discuss these points further, I am available to set up a time.

Kind regards,

Kurt Yeo
Co-founder: Vaping Saved My Life

[1]Ayo-Yusuf O. & Omole O.B. 2021. Smoking cessation advice and quit attempts in South Africa between 2007 and 2017: a cross-sectional study. Tobacco Induced Diseases, 19 (February), 11. Available:https://doi.org/10.18332/tid/132148
[2]UK Government. 2022. Nicotine vaping in England: 2022 evidence update. Available:https://www.gov.uk/government/publications/nicotine-vaping-in-england-2022-evidence-update/nicotine-vaping-in-england-2022-evidence-update-main-findings
[3]Agaku I., Egbe C. & Ayo-Yusuf O. 2021. Associations between electronic cigarette use and quitting behaviours among South African adult smokers. Tobacco Control, 31: 464–472. Available:https://doi.org/10.1136/tobaccocontrol-2020-056102
[4]Cotti C.D., Courtemanche C.J., Maclean J.C., Nesson E.T., Pesko M.F. & Tefft, N.W. 2022. The effects of e-cigarette taxes on e-cigarette prices and tobacco product sales: evidence from retail panel data. Journal of Health Economics, 86. Available:https://www.nber.org/papers/w26724
[5]Hartmann-Boyce, J. McRobbie, H. Butler, A.R. Lindson, N. Bullen, C. Begh, R. Theodoulou, A. Notley, C., et al. 2021. Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews, 9, article no. CD010216. Available:https://doi.org/10.1002/14651858.CD010216.pub6
[6]Ministry of Health New Zealand & Health Promotion Agency New Zealand. 2022. Vaping facts New Zealand. Available:vapingfacts.health.nz
[7]7NEWS Australia. 2021. Smokefree New Zealand driving New Zealand Prime Minister Jacinda Ardern (online video). Available:https://youtu.be/jxKG-RnIDcI
[8]Murray, D. 2022. Kids tapping into vape black market. Available:http://www.news.com.au/lifestyle/health/kids-tapping-into-vape-black-market/news-story/6c85e2ba2d5dd40040c1a6a66d42da8c
[9]UK Government. 2022. Nicotine vaping in England: 2022 evidence update. Available:https://www.gov.uk/government/publications/nicotine-vaping-in-england-2022-evidence-update/nicotine-vaping-in-england-2022-evidence-update-main-findings
[10]National Academies of Sciences, Engineering & Medicine. 2018. Public health consequences of e-cigarettes. Washington, DC: The National Academies Press. Available:https://doi.org/10.17226/24952
[11]Hartmann-Boyce, J. Butler, A.R. Theodoulou, A. Onakpoya, I.J. Hajek, P. Bullen, C. et al. 2022. Biomarkers of potential harm in people switching from smoking tobacco to exclusive e-cigarette use, dual use or abstinence: secondary analysis of Cochrane systematic review of trials of e-cigarettes for smoking cessation. Addiction, Society for the Study of Addiction. Available:https://doi.org/10.1111/add.16063
[12]Global Adult Tobacco Survey (GATS). 2021. Fact sheet: South Africa 2021. Available:https://cdn.who.int/media/docs/default-source/ncds/ncd-surveillance/data-reporting/south-africa/gats2021_south_africa.pdf?sfvrsn=de5704b6_1&download=true
[13]South African Government. 2008. Tobacco Products Control Amendment Act 63 of 2008. Available:http://www.gov.za/documents/tobacco-products-control-amendment-act-1
[14]UCL News. 11 March 2022. E-cigarettes not a substantial gateway to smoking for young people. Available:https://www.ucl.ac.uk/news/2022/mar/e-cigarettes-not-substantial-gateway-smoking-young-people
[15]Centers for Disease Control and Prevention. Historical NYTS Data and Documentation. Available:https://www.cdc.gov/tobacco/data_statistics/surveys/nyts/data/index.html
[16]Bickel, N.B. 19 August 2021. Current focus on preventing youth vaping could hinder adults’ efforts to stop smoking. University of Michigan News. Available:https://news.umich.edu/current-focus-on-preventing-youth-vaping-could-hinder-adults-efforts-to-stop-smoking