A response to an OP-ED:
featured on the Daily Maverick, 1 December 2020. The OP-ED was penned by Dr Sharon Nyatsanza (project and communications manager at the National Council Against Smoking) and Dr Catherine Egbe (Alcohol, Tobacco and Other Drug Research Unit at the South African Medical Research Council)
To start the following needs to be made very clear
- Nicotine Electronic Vapour Products (EVPs) are not harmless, and longterm studies are needed. However, when compared to combustible tobacco they have been reported to be vastly safer.
- EVPs fall under the category of tobacco harm reduction, and therefore should only be used by adults that want to quit smoking and have failed using other methods such as traditional NRTs (patches; gums; lozenges and inhalers); counselling; pharmaceuticals and abrupt complete cessation “cold turkey”
- They should NOT be used by people under the smoking age (South Africa been 18)
- Contrary to belief, the EVP market wants to be regulated, but regulated in an appropriate way outside of existing tobacco legislation, with a focus on safety; quality and scope for future innovation
The gist of this response is to highlight some of the inaccuracies and falsities stated in the OP-ED with links to actual research and evidence, which is sorely missing in today’s media and conversations. It needs to be understood that an estimated 1 billion people in the world are smokers with a mortality rate of 8 million per annum. In South Africa, as per Tobacco Tactics 20% of the population over the age of 15 smoked cigarettes, with mortality of 42000+ per annum. These figures paint an extremely bleak picture, and even with stricter regulations and higher taxes seen in the past 3 decades, South Africa has only seen a 13% decline in its smoking rate since 1993. The strategy isn’t working and a new approach should be considered.
“In 1993, smoking prevalence among adults was estimated at approximately 33%. The decrease in smoking prevalence occurred between 1990 and 2010, after which it plateaued around the current level.”
I’ll start with the statement:
“The e-cigarette industry, which is still largely dominated by the tobacco industry,… The top four e-cigarette manufacturers are major tobacco companies, showing an industry desperate to maximise profits from both new and old products.”
The authors would have you believe that the EVP category of products was invented by Big Tobacco, and dominate the market space. With this, Big Tobacco are up to their much-publicised old tactics in hooking new customers and hiding the facts. The truth is that Big Tobacco has only been involved with EVPs since 2012, a full 7 years after the first products were commercially available in the UK (2005) and the USA (2006). EVPs are consumer-driven products, designed; developed and manufactured by a multitude of SMEs across the globe. When researching the history of EVPs, you will learn that these products were invented and developed by individuals wishing to escape the ills associated with combustible tobacco. In regards to market domination, the independent EVP companies maintained the largest share of the global market, although this fell from over 80% in 2014 to just over 63% in 2018. The following provides a more detailed look
In South Africa, British American Tobacco South Africa (BATSA) announced a deal to acquire a local brand Twisp in 2017. Twisp started back in 2008 and has been a major EVP player in the South African market for over a decade. This deal faced opposition with the Competition Commission and was only finally approved on 13 August 2019 with limitations and restrictions for the next 5 years.
The authors then venture into the safety and health concerns of EVPs:
“Failure to regulate electronic cigarettes ignores the harmful effects of these products which are linked to severe health conditions, including cancers, respiratory and cardiovascular diseases, chest pains, mouth ulcers, asthma, and increased risk of stroke.”
As mentioned before, the use of EVPs is not 100% safe. However, any conversation on the safety and health risks associated with the use of EVPs should always be placed on the same risk spectrum as that of combustible tobacco. The primary role of EVPs is to provide a safer means of delivering nicotine, by eliminating the real danger found in smoking, the toxins and constituents found in the process of combustion. By cherry-picking literature that purposely excludes these comparisons and relying on specimen/animal testing regiments, the authors are purposely creating an environment of confusion. With over 7000 scientific reports on the topic of EVPs, the overwhelming consensus is that when compared to combustible tobacco the use of EVPs is far safer. Here are just a few snippets from leading health and scientific authorities (which the authors never refer to):
“Although it is not possible to precisely quantify the long-term health risks associated with e-cigarettes, the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure.” – UK Royal College of Physicians
“While vaping may not be 100% safe, most of the chemicals causing smoking-related disease are absent and the chemicals which are present pose limited danger.” – Public Health England
“There is substantial evidence that completely switching from regular use of combustible tobacco cigarettes to e-cigarettes results in reduced short-term adverse health outcomes in several organ systems.” – US National Academies of Sciences, Engineering and Medicine
As seen with the majority of tobacco control groups across the globe, the authors resort to the “bread and butter” of all prohibitionists, protecting the youth. Any controlled substance like nicotine and alcohol should not be used or sold to any persons under the legal age and is already stipulated in the current Tobacco Products Control Amendment Act No. 63 of 2008 Subsection 4. The law lays out the prohibition of supply and sale of tobacco products to any persons under the age of 18. Although the act does not include the EVP product category, venturing into any specialised vape shop in the Republic you will see every product that contains nicotine, to have an age restriction symbol, which is the industries attempt to self regulate and confirm to the truth, that nicotine should not be made available to the youth. I would even venture as far as to say that most (if not all) independently owned vape shops have a strict no under 18 policy. Those who are caught selling to underage people need to face sanctions.
What is particularly ironic is that the authors correctly stated that the majority of smokers started their smoking habit in their teens:
“eight out of 10 adult smokers start smoking as teenagers and are likely to become lifetime smokers.”
When taking the current position of the act and the fact that South Africa has still an incredibly high smoking prevalence, the following statements need to be aired:
- Regulations are pointless if it is not backed by enforcement and sanctions
- Are the youth obtaining tobacco products directly from retailers, or are they acquiring them through other social sources (older siblings and friends; parents and other family members) directly or indirectly? What role does parenting and eduction play here?
- The role of the illicit trade and informal traders in supplying the youth with tobacco products.
Predictably, the authors venture into the now very popular gateway effect that EVPs pose to the youth and the nicotine naive population. On face value this can be seen as a credible discussion point, considering the past 5-decade fight to reduce the smoking rate and the impact it has had on individuals and society. However, the evidence presented is unclear and doesn’t take into consideration several factors. One such factor is the number of smoking youth that have switched to EVPs as a form of harm reduction, which was highlighted by Prof John Britton, Director of the UK Centre for Tobacco & Alcohol Studies and Consultant in Respiratory Medicine, University of Nottingham:
“These findings confirm an earlier analysis of the US National Youth Tobacco Survey indicating that most American young people who use e-cigarettes tried cigarettes before vaping, suggesting that vaping is for them a rational health choice rather than a dangerous gateway into smoking.”
Another factor to consider is that these gateway studies rely on a snippet of time and don’t continue the study to reflect true causality.
“But, importantly, most of these studies have looked only at initial uptake, and not continued use, say the researchers. And for obvious reasons, no clinical trials can actually test whether e-cigarette use inevitably leads to smoking.”
But that’s not all, the authors continue with:
“Unregulated, e-cigarettes products are patently marketed to South African children. In shopping malls, colourful e-cigarette kiosks are in plain sight of children. The sleek and youthful designs, which capitalise on the world’s move towards gadgets and technology, coupled with thousands of youth-friendly flavours promote these products. Flavours like “gummy bear” increase product appeal and create a perception that these products are safe.”
There is a lot to unpack here, from colourful displays; sleek designs and “youth-friendly” flavours that are designed with the sole intent to attract the youth. Are we to assume that adults should only appreciate and be drawn to the colourless; shapeless; impractical and flavourless items in the world? That to protect our youth, adults should travel by donkey; communicate via rotary phones; wear grey overhauls and brown sandals, and eat stale bread and drink water from a tap. This is contradictory to the world that currently exists. The truth is adults like sleek designs; colourful displays; technology and more importantly for this discussion, flavours.
I have yet to understand the construct of “youth-friendly” flavours, especially if you consider that there is very little understanding of adult-friendly flavours. When doing a Google search on the term the results refer you to flavoured alcohol or other products (ice cream and candy) mimicking alcohol. Which could also open a discussion on the role of “youth-friendly” flavoured alcohol and its correlation to the youth drinking problem experienced across most of society. But let’s get back to what science and studies have shown.
According to the US Center for Disease Control (CDC) National Youth Tobacco Survey 2019, 22.3% of youth using EVPs indicated that flavours attracted them to the product. This is after the 56.1% of teens showing curiosity of the product, and 23.9% of teens indicating that EVPs were used by family and friends.
Then we need to look at the role that flavours have in assisting adults in switching from combustible tobacco. One of the most interesting discussion points highlighted in the study: “Changing patterns of first e-cigarette flavor used and current flavors used by 20,836 adult frequent e-cigarette users in the USA” – Jun 2018, was the number of adults that transitioned from tobacco flavoured EVPs to other flavours (which could be deemed “youth-friendly”) over time.
Further analysis on the topic was published in the “The role of flavors in vaping initiation and satisfaction among U.S. adults” – Dec 2019, which highlighted the following:
- Most current e-cigarette users (62.9%) typically used flavours other than tobacco (including fruit, mint/menthol, sweet, candy, coffee and other)
- Satisfaction was greater among users of flavoured versus non-flavoured e-cigarettes.
To end off the topic of protecting the youth, I would like to pose a question, which is based on not only my personal experience, but by thousands of families in South Africa and millions across the globe. How are we protecting the youth and the next generation from the loss of loved ones who currently smoke and cannot quit? How many children will grow up never knowing their grandparents? How many children will see their smoking parents struggle with debilitating health conditions? These are very pertinent questions if we consider the slow reduction in smoking rates outside tobacco harm reduction.
The OP-ED continues with another astonishing statement regarding the effectiveness of EVPs in smoking cessation:
“The Control for Tobacco and Electronic Delivery Systems Bill seeks to regulate electronic e-cigarette products as cigarettes, considering also the adverse risks of aerosols to non-users and the weak evidence of effectiveness in smoking cessation.”
This is particularly concerning if you consider that the was a systematic review “Electronic cigarettes for smoking cessation” released by Cochrane Library on 14 October 2020. Those who are not familiar with the Cochrane Review, the following will help in understanding the significance of the recent finding.
“Cochrane Reviews are systematic reviews of primary research in human health care and health policy and are internationally recognised as the highest standard in evidence-based health care. They investigate the effects of interventions for prevention, treatment, and rehabilitation.”
The review set out to evaluate the effect and safety of using EVPs to help people who smoke achieve long‐term smoking abstinence. They included 50 completed studies, representing 12430 participants, and came to the following conclusion.
- More people probably stop smoking for at least six months using nicotine EVPs than using nicotine replacement therapy
- Nicotine EVPs may help more people to stop smoking than no support or behavioural support only
- For every 100 people using nicotine EVPs to stop smoking, 10 might successfully stop, compared with only six of 100 people using nicotine‐replacement therapy or nicotine‐free EVPs, or four of 100 people having no support or behavioural support only.
- They may work better than no support, or behavioural support alone, and they may not be associated with serious unwanted effects.
Then we look to the United Kingdom, who have taken a very pragmatic approach in regulating and promoting the use of EVPs to help smokers quit. It is estimated that between 50000 – 70000 UK smokers have successfully quit each year by using EVPs. In a study funded by Cancer Research UK, the University College London released “Moderators of real‐world effectiveness of smoking cessation aids: a population study” May 2019. The study aimed to estimate the effectiveness of commonly used smoking cessation aids and test whether their effectiveness differs according to cigarette addiction, socio‐economic status, age or sex.
The study involved 18,929 people who had tried to quit smoking in the preceding 12 months, collected over a 12-year period from 2006 to 2018. Successful quitters were defined as those who reported that they were still not smoking. According to the results, people using EVPs to quit smoking are about 95% more likely to report success than those trying to quit without help from any stop-smoking aids.
The authors then venture into trust issues and the influence that tobacco companies have had on regulations and policies in the past. There is no disputing the facts that tobacco companies used every dirty trick in the book to influence and sway policymakers on regulations during the “tobacco wars”. With this the World Health Organization Framework Convention on Tobacco Control (FCTC) drafted Article 5.3 in 2003:
“In setting and implementing their public health policies with respect to tobacco control, Parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law.”
In 2008, this fairly reasonable standing evolved into Guidelines for the implementation of Article 5.3. Clive Bates (Director of Counterfactual Consulting and former Director of Action on Smoking and Health, UK) penned a brilliant piece highlighting how these guidelines could impact innovation; participation and ultimately the fight against the real issue, non-communicable diseases as a result of combustible tobacco. It is worth a read and highly recommended: “The governing idea of tobacco control” – 1 Nov 2020
This leads me to the notion “Who is watching the watchers?”. South Africa is still reeling from the influence and “capture” of government departments and SOEs by a handful of very wealthy individuals and families, and I’m afraid their impact on society and economy will be felt for generations to come. Unfortunately, we are seeing a trend whereby private groups backed by very wealthy individuals, issuing large grants to tobacco control lobbyists and government department to sway public health policies regarding SNPs (Safer Nicotine Products).
In a recent scandal involving the Philippines FDA, it has become very clear the lengths these groups will go to influence public health policies. According to Dr Lorenzo Mata, head of the Quit for Good Group:
“This is shameful and scandalous, a Philippine regulatory body receiving money from American businessmen to draft a set of regulation they cannot even get passed in their own country,”
This prompted the Samrat Chowdhery, President of the International Network of Nicotine Consumer Organisations (INNCO) to release the following statement during the recent virtual presentation of “Burning Issues: The Global State of Tobacco Harm Reduction (GSTHR) 2020” published by UK public health agency Knowledge Action Change (KAC):
“There is also an element of corruption aided by the Bloomberg NGOs, who are co-opting tobacco policy through the sheer force of money. The legislators in Philippines recently questioned the conflict of interest in their FDA receiving funds from these NGOs while pushing anti-vaping policy,”
It is yet to be seen if this level of influence has reached our shores, and the guided the current standing towards EVPs. It is therefore imperative that Article 5.3 of the WHO FCTC be amended and guard against any and all untoward influence and place a stronger emphasis on science and evidence.
To conclude this response, based on the evidence (which is ever-growing) the following needs to reiterated:
- Although vastly safer, EVPs are not harmless, and additional studies on the potential risks are always welcome. However, they should always be compared to the very well known risks associated with smoking
- EVPs should only be used by smokers who wish to quit and by users who fear a relapse back to smoking
- Current strategies to reduce the smoking rate have been stagnating for more than a decade. Amplifying these efforts will not provide the desired results and could strengthen the illicit trade even more in South Africa
- EVPs should not be used; supplied or sold to any person under the legal age (18)
- EVPs are not Tobacco
- Innovation in hardware and flavours is critical to the success of EVPs
- The success of EVPs as a quit smoking aid is incredibly promising in a properly regulated environment. Treating EVPs as a solution and not a subsection of the problem is a step in the right direction
- If the ultimate goal is to reduce the smoking rate and the impact on individuals and public health, lobbyists and policymakers need to review all available science, report accurately and approach the matter pragmatically.
- Policymakers and the regulations they put forward should be free from any and all influencers across the spectrum and should rely solely on science and evidence.
In closing, consider the following from Dr David Abrams, Professor of Social and Behavioral Sciences, School of Global Public Health, NYU
“I think we’ve forgotten that 120 years ago, the disruptive technology was the cigarette rolling machine that literally caused this epidemic of lung cancer and other diseases. And now we have an opportunity 120 years later to get rid of the cigarette with a new technology that delivers nicotine in a very satisfying way without the major harms of burning tobacco. If we lose this opportunity, I think we will have blown the single biggest public health opportunity we’ve ever had in 120 years to get rid of cigarettes and replace them with a much safer form of nicotine for everybody.”