Research on e-cigarettes conducted by prominent public health researchers in South Africa 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 the country.
Lekan Ayo-Yusuf, executive director of the Africa Centre for Tobacco Industry Monitoring and Policy Research (ATIM) at Sefako Makgatho Health Sciences University, said the research results support an urgent need for a regulated environment in order to better protect the 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,” says Mr Ayo-Yusuf, a professor.
“These series of studies provide very useful information to guide policy makers in South Africa.”
The series of three studies, conducted by the ATIM 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. Finally, geospatial mapping was used to understand the distribution of vape shops across South Africa and how this may impact youth usage.
Based on two large population-level surveys, the prevalence study shows a growing prevalence of regular e-cigarette use by South Africans older than 16 years. 2.71% of adults, translating to 1,09 million people, used e-cigarettes during 2018. Most of these e-cigarette users were concurrently regularly smoking cigarettes.
The second 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 patterns among past quit attempters using e-cigarettes. The study shows that awareness of cessation aids among current smokers was 50.8% for smoking cessation programmes; 92.1% for nicotine replacement therapy; and 68.2% for prescription cessation medication.
Among current combustible smokers who attempted to quit in the past, ‘ever’ e-cigarette users were more likely than ‘never’ e-cigarette users to have used other cessation aids. Furthermore, among current smokers who had ever attempted to quit, past users and over half of current e-cigarette users were more likely than ‘never’ e-cigarette users to have used cessation aids.
For ‘ever’ smokers (cigs) who had tried to quit, e-cigarette use was associated with a higher likelihood of short-term, but not long-term quitting. The study in fact 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, the study also suggests more e-cigarette ‘ever’ as compared to ‘never’ users still believed 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 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 over a one-year period. Annual cost associated with daily use was R6,693 (about N166,000) for manufactured cigarettes and up to R19,780.83 (N490,000) for e-cigarettes. According to this study, implementing excise taxes on e-cigarettes at 75% of the cigarette excise tax rate could generate annual revenue of up to R2.20 billion (about N55 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 NHI funding,” says 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 ‘ever’ using an e-cigarette,” says 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 a 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 Mr Ayo-Yusuf.
Mr Ayo-Yusuf said that advocacy groups and researchers can maintain vigilance in relation to the tobacco industry, to identify and publicize any evasive or deceptive marketing. He tasked clinicians to 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.
He further urged pharmacies to voluntarily remove e-cigarettes from their shelves as a health promotion initiative, and parents and caregivers to 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,” he says.
“We all have a responsibility to remain aware and vigilant in protecting the health of our people.”
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