E-cigarettes - the slow way to poison yourself?

It’s billed by the purveyors of the Electronic nicotine delivery systems (ENDS), as pure as a breath of water vapour from a mountain waterfall ... You get your nicotine kick, plus the oral fixation - but without the tobacco and its 7 000-plus chemicals. Think e-cigarettes will help you quit....

Think again.

There is as yet no known safe way to suck a non-medicinal drug into your lungs. While the much lower levels of nicotine in e-cigarette vapour don't cause acute poisoning, doctors are concerned about possible effects over the long term.

For the uninitiated, you don't smoke these pleasure-sticks, you “vape” them, because that's all you're inhaling. The device heats a solution to form water vapour, laced with a shot of nicotine and maybe some tasty fruit flavouring.

Nicotine stimulates the cardiovascular system: It elevates heart rate and blood pressure, which can be dangerous in people with heart problems.

Professor Richard van Zyl-Smit, head of Lung Clinical Research at the University of Cape Town's Lung Institute, says that nicotine may act as a tumour “promoter” by stimulating angiogenesis, the proliferation of blood vessels that feed a cancerous growth.

A highly addictive poison

There is also evidence that nicotine could affect foetal development, although major congenital effects have not been shown.

And let's not forget nicotine's main attribute: It's highly addictive, probably as addictive as heroin and cocaine. It’s the reason there are still one billion smokers worldwide, and six million tobacco-related deaths every year.

It's true that nicotine isn't the worst culprit in cigarettes compared to tar and carcinogens, but it's a potent substance nonetheless.

“It's a poison,” says van Zyl-Smit bluntly. “When I order nicotine for experiments in my lab, the container it comes in says Poison – don't drink the stuff.
“Passive” e-cigarette smoke hasn't been shown to be harmless to the satisfaction of many doctors either, says van Zyl-Smith. “Non-smokers don't want to be exposed to something 'less dangerous than smoke'. Non-smokers now expect they shouldn't have to endure exposure to anything other than fresh air.”

Medical response to the ENDS party has been almost unanimous: Sorry, but no cigar.

In August, a World Health Organisation (WHO) report called for strict regulation of ENDS: bans on e-cigarette advertising, sales to minors and public indoor use, and on claims that they aid smoking cessation.

'Filled with promise'

The report doesn't slam e-cigarettes completely though, conceding this is “an evolving frontier, filled with promise and threat for tobacco control”.

Dr Yussuf Saloojee, Executive Director of the National Council Against Smoking (NCAS) echoes this: “Revisions are being made in this field almost on a daily basis. The NCAS isn't against e-cigarettes, but we need more evidence on the health effects before we can endorse them. They're still so new – they've only been around for a decade.”

Most of the heavy-hitter health advocacy bodies side with WHO, including the American Heart Association, the European Respiratory Society and our own Cancer Association of South Africa (Cansa).

Regulatory bodies like the US Food and Drug Administration (FDA) are taking the WHO recommendations seriously and moving to tighten up ENDS regulation. Most controversially, several US States have already banned vaping in public venues.

Bans on public use in particular have caused an outcry, both from disgruntled vapers who complain it's yet another way “nanny” authorities are curtailing their freedom, and from some members of the medical establishment itself.

In September, several top tobacco experts criticised the WHO report in the journal Addiction. Professor Ann McNeill, lead author from the National Addiction Centre, King’s College London, said in Addiction that she and her colleagues found the report overly negative. WHO’s approach, she said, will make it harder to bring e-cigarettes to market and will deter smokers from using them, thus potentially foregoing the public health benefits these products could have.

“We certainly don’t yet have all the answers as to their long-term health impact, but what we do know is that they are much safer than cigarettes,” said McNeill.

Van Zyl-Smit adds that it's not just water vapour ENDS are delivering.

Generally safe

The vapour typically consists of propylene glycol, sometimes glycerol and flavourants, and the all-important nicotine (though some e-cigs contain none).

Propylene glycol, a common additive in foods and medicines, and also used to make fake smoke in the entertainment industry, is deemed “generally recognised as safe” by the FDA. Glycerol is an organic compound used extensively in pharmaceuticals and also of little concern.

But given that quality control of many ENDS products is poor, it's often unclear what other chemicals may be present and in what concentrations. Carcinogens like formaldehyde have been found in the vapour, as well as other toxins – albeit at levels considerably lower than in cigarette smoke.

Then there's the nicotine itself.

The rise in ENDS use has seen a rise in severe nicotine poisoning cases in children and pets overseas. The risk comes mainly from ENDS liquid refills, which have a much higher nicotine content than the vapour.

Pharmacist Linda Curling from The Poison Information Centre at Red Cross Children's Hospital says: “There seems to be fairly high use in the young adult population, which is worrying because that group are likely to have young kids. Twisp has assured us their liquid refills come in childproof packaging, but these products should nonetheless be treated like medicines and kept out of children's reach.”

A possible gateway

The other concern public health advocates have with ENDS is the potential effect on smoking behaviour. If it turns out they significantly help smokers quit tobacco, even if it means users carry on using nicotine, then the boon to public health would be hard to fault.

But studies to date have been disappointing in this regard, and quit/cut-down success stories largely anecdotal. All e-cigarettes may really be doing is turning smokers into dual users of both conventional and e-cigarettes, with only a negligible drop in the amount of tobacco smoked.

Even more troubling, e-cigarettes may act as a gateway for young never-smokers to smoking proper.

Anti-tobacco advocates don't like how ENDS marketing mimics 20th century cigarette ads. The trendy packaging, flavouring, and cool celebrities like Stephen Dorff vaping in commercials strongly suggest an industry intent on getting youth hooked on their product – a well-worn tobacco company ploy.

Highly visible advertising and public use of e-cigarettes could also “re-normalise” smoking: it's been proven that the public presence of cigarettes (or cigarette-like devices) and smoking makes the habit appear more acceptable; it's also a big trigger for smokers trying to quit.

Van Zyl-Smith says that if you're planning to give vaping a try, to at least consider waiting six months to a year, during which he reckons there will be an “explosion” of laboratory studies on ENDS.

“These won't be the real-world epidemiological studies that we need to gauge long-term effects; remember, tobacco-related diseases took decades to show up. But the lab studies will give us a clearer picture of the risks.”

Vaping: Who really benefits?

Then there’s the issue of who the big industry players are.

There are an estimated 466 brands of ENDS and global sales amounted to $3 billion last year. The initial outlay for a Twisp starter kit (South Africa's leading brand), for example, is around R1 000, plus R200 a month for the liquid refill.

An unpalatable aspect of the market is that the beneficiaries of this could increasingly be the tobacco companies.

Initially, small private companies were the ones selling e-cigarettes, which are manufactured mainly in China and the Philippines. Now, increasingly, the big tobacco companies are getting in on the action.

Cigarette sales have dropped in recent years, especially in the first world, causing Big Tobacco to seek out lucrative additions to their main product, or, as they put it, “reduced harm alternatives”: smoking, but better-for-you smoking.

This year, for example, Philip Morris International bought NicoCigs, one of Britain's biggest e-cigarette makers, while the Imperial Tobacco Group snapped up the top-selling “blu” e-cigarette brand. In 2013, through their subsidiary business Nicoventures, British American Tobacco (BAT) launched the e-cigarette Vype.

BAT gushes that “Vype is just the beginning – we’re investing millions of pounds, conducting scientific research and using consumer insights to further develop e-cigarettes.”

Saloojee says in South Africa, however, to his knowledge the tobacco companies have not moved in on the ENDS market yet.

Neither BAT SA nor Philip Morris, the two biggest multinationals operating in this country, are selling e-cigarettes here, and they both say they have no immediate plans to do so. Whether “immediate” means “not next week but maybe next year” remains to be seen.

The biggest player in the ENDS industry in SA, and the most transparent in terms of what goes into its products, is Twisp, which has also been in the business since 2008.

Philip Bartholomew, co-owner at Twisp, says his company is “far ahead” of the competition both in terms of market share (around 60-70%) and quality control of their product.

“The e-cigarettes available out there, mostly sold on the internet, could come from 100 different factories in the East – really, any name can be stamped on them, and we don't have a good idea of what they contain,” he says.

Twisp's “hardware” also comes from the East, although the device was designed by Dutch firm Janty. The refill liquid is made by a local pharmaceutical company, which Twisp prefers not to name.

“You need quality control because poor products ruin the perception of what are still quite new products. In 2011 we saw a drop-off in sales because a bad disposable e-cigarette [not one of Twisp's] came on the market, where the hardware broke down.”

Bartholomew concedes that e-cigarettes exist in a grey area, neither recreational nor medical. “We'd like clarity from the Department of Health on this and we welcome reasonable regulation of the industry.”  

E-cigarette legislation: pretty hazy

In SA, the law pertaining to e-cigarettes is also hazy. The Medicines and Substances Control Act was amended in 2012 as regards nicotine: It states that ENDS are scheduled devices that should be bought at a pharmacy with a doctor's prescription.

Two years later, this regulation is clearly not being enforced, with e-cigarettes being sold in mall kiosks and other non-pharmacy stores. It seems local e-cigarette sellers have been getting away with this by making no explicit claims that their products are medical devices, have health benefits, or help with smoking cessation.

Worldwide, ENDS regulation varies widely, from regions with no restrictions to others banning the devices outright. But many countries, South Africa included, are leaning towards tighter controls.

In February 2014 the European Parliament passed regulations including quality control, disclosure of ingredients, and bans on advertising of e-cigarettes. The FDA's proposed regulations, published April 2014, are along similar lines.

Mark van der Heever, spokesperson for the Western Cape Department of Health, says that as ENDS don't contain tobacco, they can't be read into the definition of "tobacco products" in terms of the Tobacco Control Act, which provides SA with one of the world's tightest set of smoking laws.

“But ENDS products resemble cigarettes, so they can be seen as challenging the denormalisation of tobacco use. For this reason, the Department is considering amendments to the legislation, to ensure e-cigarettes are regulated," says van der Heever.

Until then, allowing vaping in public spaces like malls and restaurants will be left to the discretion of owners. Transgressions of the Medicines and Substances Control Act, says van der Heever, should be reported to and dealt with by the police and local authorities.

Nearly everyone engaged in the e-cigarette debate agrees that “E-cigarettes are probably not as bad for you as cigarettes”. This is a pretty safe claim, considering that cigarettes are disastrous for you.

It may turn out that the health risks of vaping are negligible, but until we know more, you vape at your own risk.  

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