/ 28 August 2014

Where there’s smoke, there’s fire

Elegant: E-cigarettes may not be as toxic as regular cigarettes
BAT said developed markets remained relatively resilient despite the pandemic, but the health crisis has seen supply chain restrictions negatively affect sales in Canada, Mexico and — as a result of a five-month tobacco trading ban — South Africa.

“I wish I never smoked in the first place and moving over to electronic cigarettes [e-cigarettes] was my way of trying to kick the habit but my nicotine addiction has increased – now I want to smoke all the time,” says Brett Pearton (47) from Randburg in Johannesburg, shaking his head with regret. “Going ‘cold turkey’ [giving up a habit abruptly] is the only way.”

Pearton started smoking when he was only 15 and now, 32 years on, he’s battling an ongoing nicotine addiction that, according to him, has been worsened by smoking e-cigarettes, which he had hoped would eventually help him to quit the habit altogether.

The Forum of International Respiratory Studies, which comprises professional organisations and experts in respiratory diseases, says battery-powered e-cigarettes were first produced in China in 2003 and come in various shapes and sizes, according to their July position paper published in the American Journal of Respiratory and Critical Care Medicine.

The device, which is now common in South Africa, has a small cartridge filled with a liquid containing nicotine (commonly known as “juice”), as well as an atomiser that attaches to the battery, according to the forum. The atomiser heats the cigarette and turns the liquid into vapour, which is then inhaled by the user.

Not regulated
Although often touted as a “healthier alternative” to smoking tobacco, there have been concerns about the contents of these products as they are not regulated.

The tobacco epidemic, described by the World Health Organisation (WHO) as the biggest public health concern, kills nearly six million people each year. According to the United States government’s Centers for Disease Control, people who smoke are “15 to 30 times more likely to get lung cancer or die from lung cancer than people who do not smoke”. The centre says cigarette smokers are also “two to four times more likely to develop coronary heart disease than nonsmokers”. Furthermore, they are at double the risk for a stroke than nonsmokers.

The forum says there is considerable variation in nicotine levels in e-cigarettes. “Manufacturers of e-cigarettes report that each replacement cartridge typically contains between six and 24mg of nicotine, but [it] may contain more than 100mg.”

The potential benefits of e-cigarettes to an individual smoker, says the forum, “should be weighed against [the] potential harm to the population of [the] increased social acceptability of smoking and use of nicotine”.

Euromonitor International, a global tobacco industry watchdog, says on its website that the growing popularity of the devices has exceeded expectations; this year’s projected sales for e-cigarettes in the US are pegged at $1.7-billion.

In South Africa a starter pack bought from the chain-store pharmacy Clicks costs R699; a refill of nicotine liquid is R200.

Growing addiction
A technician with Telkom, Pearton is one of the growing number of South Africans who have taken to “vaping”, as the practice is commonly known, and, although he has not smoked a normal cigarette in 18 months, he is worried his nicotine addiction has grown stronger because he smokes his e-cigarette many more times a day than when he smoked tobacco.

“Three years ago my mother fell sick from the effects of years of smoking. It affected me badly and I made a decision to work towards giving up smoking,” he says.

Pearton’s mother recovered and soon swapped her normal cigarettes for e-cigarettes.

“I was impressed by the progress that my mom made. Her coughing and breathing improved immensely and I also decided to try them.”

But three weeks ago his mother was rushed to hospital with a lung-related condition. Ravaged by years of smoking, Pearton says his mother’s doctor told him that her body is still fighting to rid itself of the poisonous chemicals in the tobacco that she used to smoke.

“She was very sick and it has affected the whole family to watch her suffer like that,” Pearton says.

Research lacking
Although Pearton’s new habit works better for him than normal cigarettes – there are no unpleasant smells and it is cheaper (he used to spend R1?200 a month on conventional cigarettes, but is now down to R300) – he is worried that no conclusive research on its safety has been done.

As the debate on e-cigarettes rages on, a scientific review of the available research published in the peer-reviewed journal Addiction last month did not find any adverse health effects for those using e-cigarettes.

The researchers say, based on the data available, e-cigarettes do not deliver toxicants that are linked to cancer, chronic lung disease and cardiovascular disease and are less likely to be harmful to users or to bystanders.

But other researchers from the University of Athens, in a small study of 30 smokers published in the online scientific research database PubMed, found that e-cigarettes can cause damage to the lungs.

Tobacco relapse 
Pearton is concerned that his nicotine addiction has become worse, making him more susceptible to relapsing and smoking tobacco cigarettes, especially when his battery is flat or if he is out of nicotine liquid.

“I smoke more and have now become dependent on the e-cigarette. It is very hard when I cannot smoke them for whatever reason [out of liquid or flat battery] and it makes me crave for normal cigarettes, but I just have to remain strong,” he says.

Head of the lung clinical research unit at the University Of Cape Town, Richard van Zyl-Smit says that e-cigarettes could in fact encourage more habitual use of nicotine, which, in time, might lead a user to switch back to tobacco smoking.

“E-cigarettes contain nicotine, which is toxic and addictive. Nicotine potentially opens the door to chemical tolerance, and long-term users may seek increasingly higher nicotine concentrations, ultimately resorting to tobacco,” he says.

Van Zyl-Smit views e-cigarettes as a way to maintain nicotine addiction.”E-cigarettes are advocated as a ‘healthier alternative’, because it doesn’t involve inhaling tobacco smoke, but the obvious long-term addiction to nicotine remains unaddressed,” he says.

Van Zyl-Smit insists that, until there is credible data on the safety of e-cigarettes, people should be wary of adopting the new craze. “The contents of e-cigarettes, which include nicotine and propylene glycol, are not completely safe. Nicotine is poisonous in high doses; it affects your cardiovascular system as well as [your] immune system,” he says.

“Although there are no reports of anybody dying from smoking e-cigarettes yet, while cigarettes kill 50% of smokers, it took us 50 years to demonstrate that tobacco causes cancer,” he adds.

No health benefits
Van Zyl Smit also dismisses “unsubstantiated” reports that e-cigarettes have some health benefits.

“I can see absolutely no health benefits for smoking anything. Nicotine is an addictive drug and has effects on the body, which is why people smoke in the first place: they ‘feel better’ after a cigarette,” he says.

“I would not advocate use of e-cigarettes to anyone except if they are desperate to quit smoking and want it as an alternative during the quitting process. The ultimate goal, however, must be to quit smoking altogether,” he says.

Meanwhile, calls for stricter regulation of e-cigarettes are getting louder. In April the US Food and Drug Administration centre for tobacco products proposed regulations that would ban the sale of e-cigarettes to minors and required manufacturers to register with them and give a detailed accounting of the ingredients.

A European Commission directive was issued earlier this year on the safety of e-cigarettes. From 2016 electronic products containing nicotine are to be regulated as medicines in the United Kingdom.

In June this year over 100 public health professionals from all around the world sent a letter to the World Health Organisation, agitating for stricter controls on e-cigarettes.

Regulation in SA
Van Zyl-Smit agrees that e-cigarettes have to be regulated.

“The big question that regulators are struggling with is: Are they a medicine or a health product, or a tobacco product? – each having very different regulatory framework,” he says.

Nicotine is classified as a schedule three substance, which requires a prescription from a doctor, under the Medicines and Related Substances Act in South Africa; other products containing the addictive substance are regulated as medicines.

But e-cigarettes’ regulatory status in South Africa is still unclear and because of this they are freely available without a prescription.

“They should be sold in a pharmacy as they contain nicotine, but as yet that is not enforced,” says Van Zyl-Smit.

“To protect the end consumer you have to know what is in the device, you have to be certain that the manufacturing process is good and that they are not contaminated with other chemicals, and you need to protect children,” he says.

Pearton agrees: “What’s particularly important is educating the youth on the negative health implications of smoking and empower[ing] them to make informed choices, so they don’t end up like me.”

Phyllis Mbanje is a Bhekisisa fellow