The risks that e-cigarettes hold

 e-cigarettesIn recent years the global electronic cigarette (e-cigarette) industry has evolved into a $3-billion business with 466 brands: there was only one manufacturer in 2005. Electronic nicotine delivery systems (ENDS), of which e-cigarettes are the most common prototype, are battery-powered devices that use electricity to aerosolise a nicotine-containing fluid for inhalation.

Nicotine is addictive and is not harmless. But as ENDS are not made from tobacco leaves, they have largely escaped regulation. The global growth of ENDS represents an evolving frontier filled with both promise and threat for tobacco control. There is a need to regulate the use of ENDS to maximise their potential and minimise health threats.

ENDS are frequently marketed by the industry as an aid to quit smoking or as a healthier alternative to tobacco. The argument is that they don’t contain the toxic by-products found in cigarettes, such as tar, and do not produce smoke. But there has been very little research on ENDS and no convincing evidence that they are effective as a “quit-smoking device”. In fact, with almost 8000 different flavours added, including fruit and candy-like flavours, there is legitimate concern that instead of reducing the number of smokers they will serve as a gateway to nicotine addiction, and ultimately, smoking, particularly for young people. Evidence supports this — experimentation with e-cigarettes is growing among adolescents, the figures doubling between 2008 and 2012.

Existing evidence shows that ENDS aerosol is not merely “water vapour”. It contains cancer-causing agents, such as formaldehyde, which in some brands reach concentrations close to that of conventional cigarettes. They deliver nicotine, which we know is a potent vasoconstrictor that may contribute to cardiovascular disease. There is sufficient evidence to show that nicotine itself, and not just the smoke from cigarettes, can affect brain development in foetuses and among adolescents just from passive inhalation. ENDS contain varying levels of nicotine. Frequently, these levels are similar to those in cigarettes, and without regulation there is no way to control this amount. There is also evidence that the use of ENDS indoors increases second-hand exposure of non-smokers and bystanders to nicotine and a number of toxicants. While some evidence does show that ENDS are likely to be less toxic than conventional cigarettes, it is not known how much less toxic they are. Until we have sufficient evidence to determine the extent of their health impacts, the industry must be regulated. If we wait to implement regulations till research findings are available, it may be too late.

While some steps have been taken to regulate ENDS, there are huge policy variations among countries. Singapore and Brazil have banned e-cigarettes. In the WHO South-East Asia Region, many countries are considering regulations. In India, a governmental round table discussion in July 2014 decided to consider banning ENDS. While these are steps in the right direction, several countries in the developing world have no regulations or measures to regulate e-cigarettes.

It is for this reason that WHO recently released a Report on the Regulation of ENDS. It will be the primary topic of discussion at the Sixth Session of the Conference of the Parties to Framework Convention on Tobacco Control (FCTC), to be held from October 13 to 18 in Moscow. In the report, WHO calls for regulations to prohibit the addition of flavours that may make ENDS more attractive to youth, ban the use of ENDS indoors and in public and workplaces, and restrict its advertising, promotion, and sponsorship to ensure that adolescents and non-smokers are not targeted. The regulations should impede ENDS promotion to non-smokers and young people, minimise potential health risks to users and non-users, prohibit the dissemination of unproven health claims, and protect existing tobacco control efforts.

WHO is urging countries to choose the best regulatory framework available to implement the regulatory objectives. In some cases, this might be the existing tobacco control legislation, or medicines and medical devices regulations. In other cases it may be elsewhere in the government sector. Regardless, the regulations must be implemented in a timely manner to protect the public from any potential ill-harm while more tests regards the health impacts of ENDS are carried out. The regulations should be adaptable to new data as they are gathered on the health impact of ENDS.

We have made remarkable progress in terms of tobacco control, but the increasing popularity of e-cigarettes threatens to undermine years of hard work. There is urgent need therefore to act now, to protect public health.

By Poonam Khetrapal Singh,

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