Even though traces of cancer-causing chemicals have been found, the real killer – tobacco – is absent.
A study by the French consumer organisation, the National Consumers' Institute, has found harmful chemicals in electronic cigarettes, sparking renewed concerns about the products that are often hailed as a healthier alternative for smokers.
After testing for cancer-causing molecules in the vapour from 10 e-cigarettes, three types of e-cigarettes tested positive for the chemical formaldehyde at levels close to those of typical cigarettes. The toxic compound acrolein, which changes to vapour when heated, and which has been shown to damage the lungs, was also found. For some e-cigarettes, acrolein levels were higher than in normal cigarettes.
However, many experts have discredited these findings. Clive Bates, a former director general with the Welsh government and an international anti-tobacco activist, said on his blog that the study was "not published in a peer-reviewed journal, its provenance is unclear and the interpretation of its findings is very poor".
Electronic cigarettes have been lauded, albeit controversially, as a healthier alternative to normal cigarettes, which could help to lessen the burden of disease caused by conventional tobacco smoke.
Derek Yach, the senior vice-president of the Vitality Group, part of South Africa's largest medical scheme, Discovery Health, said the levels and types of chemicals found in electronic cigarettes are similar to those found in approved nicotine inhalers sold at pharmacies.
"There's no tobacco in the product, so the potential cancer risk should be dropping to close to zero. Even if it's not exactly zero, the consequences of taking tobacco out of people's lungs and bodies will be huge for cardiovascular disease as well as lung and other cancers," he said.
According to Yussuf Saloojee from the National Council Against Smoking, an electronic cigarette is essentially a "metal tube with a small cylinder in the middle which contains liquid nicotine and a battery- operated heating element. When the nicotine is heated, it becomes a vapour, which is then inhaled."
Yach, who previously headed the World Health Organisation's Tobacco Free Initiative, which was responsible for the first global treaty on tobacco control, said: "[Electronic cigarettes are] something we are exploring within the Vitality programme [a wellness initiative that rewards members for getting healthier] since we know current approaches to get smokers off tobacco, including the use of nicotine replacement therapies, are simply not sufficiently effective."
SA smokers have halved
The government's tobacco control policy, which includes a ban on advertising, restricting smoking in public spaces and heavy taxing of tobacco products, has halved adult smoking over the past 20 years, according to the Human Sciences Research Council, which showed, in the South African National Health and Nutrition Examination Survey it published last month, that the percentage of adults in the country who smoke has dropped from 32% to 16.4%. The survey also found that, among current smokers, 48.1% had tried and failed to quit in the past year. However, Saloojee said that about 30?000 to 40?000 deaths in South Africa every year can still be attributed to tobacco smoke.
"In theory, electronic cigarettes should be safer than cigarettes because cigarette smoke contains 5?000 different chemicals, but electronic cigarette smoke should just contain nicotine and a relatively harmless carrier chemical," he said.
"But there might be other undeclared dangerous chemicals, and it would be irresponsible to advocate for their use as an alternative for normal cigarettes before more research is done."
Yach agrees. "Without enough evidence, we are a little sceptical [about e-cigarettes] but we do believe that there is a huge potential to bring down the death rates fast."
Electronic cigarettes are growing in popularity around the world and, according to Yach, they're a $1-billion revenue category in the United States. "The industry's growing so fast that a number of leading investors argue that it could capture up to 40% of the regular cigarette market in developed countries before long."
E-cigarettes classified as 'medicines'
Saloojee said that there is no data on e-cigarette use in South Africa. One can buy e-cigarettes online or from a number of retailers without a doctor's prescription in the country. A change to the schedules published in terms of the Medicines and Related Substances Act last year classified nicotine when used as "a substitute for a tobacco product" as a schedule three substance. Schedule three substances require a prescription and should only be sold at pharmacies.
"The intent of the schedule three inscription was to clearly capture unregistered delivery devices containing nicotine, including electronic cigarettes," said Andy Gray of the University of KwaZulu-Natal's pharmacy department. "They cannot be considered to fall under the Tobacco Products Control Act because they do not contain tobacco."
However, Gray said that because no clear regulatory action has been taken regarding electronic cigarettes, this scheduling stipulation is "clearly not being applied with any vigour".
The regulation of e-cigarettes as a medical product has been a topic of international debate. The Medicines and Healthcare Products Regulatory Authority announced in July that e-cigarettes would be regulated as medicines in the United Kingdom from 2016.
Medical regulation could hamper progress
Yach said that the "potential positive disruptive power" of electronic cigarettes could be overshadowed by regulating them as medical devices. He believes they should be treated like any other consumer product that is subject to the South African Bureau of Standards' approval.
According to Yach, regulating electronic cigarettes as pharmaceutical products would "hinder further development" of these products, "which is essential for electronic cigarettes to become a full replacement for cigarettes".
He said that medical licensing is expensive and has strict requirements with long time scales that would deter developers from creating improved and safer versions of the product.
"My hope is that, before [the government] takes any action, it should be commissioning or agreeing on research," Yach said.
For example, he said, we need to know what impact electronic cigarettes will have on a smoker compared with traditional methods to stop smoking, such as nicotine patches or gum, because those methods have not proved to be very successful.
"On smoking cessation, the best success we have in the world is by using financial incentives (rewarding people for stopping). All the other methods give you about 5% to 8% cessation [at the end of a year]. If on electronic cigarettes we could double that or go even higher, think about the lives we'll be saving."