In South Africa nicotine-containing e-cigarettes have fallen through the regulatory cracks in our current legislation, leading to unrestrained sales to teen vapers.
WORLD NO TOBACCO DAY: Electronic cigarettes have sparked the interest and curiosity of young people across the globe with millions of them smacking their lips over an array of almost 500 e-cigarette brands. Although e-cigarette marketers claim that their products are specifically designed and promoted for adult use, it appears that adolescents and youth are not immune to their glowing attributes. With concerning health issues emerging last year among young vapers in the United States, there is a need for e-cigarette makers to take accountability for zealous marketing strategies and for legislators to fast-track protections for young people.
Originally devised as tobacco smoking cessation tools or alternatives to tobacco, e-cigarettes today are strongly marketed as leisure products, commonly depicted as delectable, discerning, trend-setting and healthier alternatives to cigarette smoking.
In South Africa, nicotine-containing e-cigarettes have fallen through the regulatory cracks in our current legislation, leading to unrestrained sales and marketing. Because they don’t contain tobacco, e-cigarettes are not regulated by the Tobacco Products Control Act No. 83 of 1993. Nicotine itself is regulated under the Medicines and Related Substances Act No. 101 of 1965, as a Schedule 3 substance (thus requiring a prescription). But Zamathiyane Mthiyane, a senior associate at Werksmans Attorneys, explains that e-cigarettes remain unregulated given that only nicotine products used as an aid to smoking cessation or as a replacement, and which contain a nicotine content of 10mg or less per cartridge, are considered to be a scheduled substance. Furthermore, e-cigarettes do not meet the Act’s definition of a “medical device” and are thus excluded from the ambit of the Act.
Absent regulation and a burgeoning local market, which British American Tobacco (BAT) estimates at around 1.5 million vapers, has not only increased the appetite of major multinational tobacco companies who use their considerable resources to attract users. It has also led to the proliferation of mom-and-pop stores with at least 231 shops and fourteen online stores selling e-cigarettes in South Africa. This doesn’t include a thriving second-hand market that is tapped by many young vapers.
There is a dearth of statistics on e-cigarette use specifically among young people. Zanele Mthembu from the Campaign for Tobacco-Free Kids (CTFK) says that anecdotal evidence suggests the country is sitting on a silent epidemic of underage users. Overseas, national surveys conducted in 2019 and 2018 in the United States and the United Kingdom point to millions of users. In the US, five million school children from ages 11 to 18 had used e-cigarettes in the past-thirty-day category, and nearly one million reported daily use. This was an increase from 3.6 million in 2018. In the UK, one in six British children aged between 11 and 18 admitted to having tried e-cigarettes. The US survey noted that while cigarette smoking was at an all-time low among high school students, e-cigarette usage had increased, thus reversing the overall decline in youth smoking.
What’s the big deal?
There are consequences for young vapers. Professor Richard van Zyl Smit who heads the Lung Clinical Research Unit at the University of Cape Town Lung Institute, cautions against vaping in general, but particularly in youth: “If you are vaping as an adolescent or teenager, your lungs are still growing. Maximum lung capacity is only developed at roughly 20 to 25 years of age. Young vapers may ‘stunt’ their lung growth and not reach their maximum peak.”
Concerning reports emerged last year in the US of a severe vaping-related lung injury and toxicity among American adolescents. By the end of the year there had been almost 3,000 hospitalisations exhibiting similar symptoms, and 68 deaths. Known as “e-cigarette, or vaping, product use-associated lung injury” (EVALI), there are a number of theories about its recent emergence. van Zyl Smit says that it appears to be the result of something in the vape liquid – often from less well-known or self-made, non-commercial liquids. However, he adds, another theory is that teenagers are vaping far more than expected and so it may be a volume issue.
Could it be that teenagers are unwittingly overdosing themselves? During an interview with this writer, young South African vapers claimed that while cigarette or hookah-pipe smoking would ordinarily give them a headache with overuse, this doesn’t occur when vaping the fruity or dessert flavours of e-cigarettes.
We be lit
To understand the key drivers for e-cigarette usage in young people, South Africa has had to draw inferences from global markets. However, a recent qualitative study conducted by an academic at the University of Cape Town sheds some light on what young people currently think about vaping. The study which was published in February 2019 by Pakhani Mhazo as a Masters’ thesis, in partnership with the Cancer Association of South Africa (CANSA).
Many of the participants, ranging in age from 18 to 25, claimed exposure to e-cigarettes while they were still in high school and younger than 18. They were driven to e-cigarettes out of curiosity and a “coolness” factor. “Classy” and “fashionable” were other adjectives that the participants used, with the study noting that e-cigarettes were perceived as a symbol of aspirational wealth and social standing. For them, information about e-cigarettes was primarily gleaned from e-cigarette websites and social media.
Kyle, Troy and Dineo (not their real names) who are 17, 18 and 21 years old respectively, tell this writer that they have been vaping for about three to four years. All three were attracted to vaping by the tricks that can be performed by blowing vapour into a variety of shapes and patterns. Regarded as something of an art form that has fast developed into a sub-culture with its own lingo and “cloud chasing” social media personalities, Troy says, “There is a whole community on YouTube and Instagram.”
In 2019, a group of researchers from Yale and Stanford analysed the content of fifty-nine YouTube videos that promoted vape tricks, and found that while the people performing vape tricks in the videos were predominantly males between 18 and 24 years of age, nearly half of the videos were directly produced by vaping marketers or vape stores.
Mea culpa, moving on
The claims that e-cigarette companies market to young people is often categorically denied. But popular US vaping company Juul Labs currently faces a lawsuit for having previously purchased advertising space on youth-focused websites. Tobacco company Philip Morris International (PMI) came under fire last year for a global social media marketing campaign that used young online personalities (including one under 21) to drive awareness of IQOS, its heated tobacco device. PMI claimed a “breach” of campaign guidelines which specified the use of age 25+ influencers, said mea culpa and suspended the campaign.
A few months later Philip Morris South Africa (PMSA) was scrutinised for paying for popular social media influencer, Pearl Modiadie, to attend the Milan Design Week and to promote stories to her 2+ million Instagram followers about IQOS at the event. Modiadie, 32, was one of at least five prominent social media influencers who had posted about IQOS in 2019. When probed on the matter, PMSA was less eager to say mea culpa and responded that many companies cover travel and accommodation costs for the media that they invite to write about their brands.
In November last year, PMSA launched a marketing campaign on dating app Tinder. Coinciding with International Singles Day, the campaign entitled “Unsmoke the world, one match at a time” dovetailed with PMI’s global “smoke free future” campaign with a banner linking from the Tinder app through to the “Unsmoke Your World” website. Here people are ostensibly told to quit smoking but if not, to use alternatives like a heated tobacco product.
Regardless of how marketers put the spin on their campaigns – or dialogue, as the case may be – there is no denying the appeal of e-cigarettes for young people: the IQOS stores in South Africa are reminiscent of upmarket fashion boutiques; and the numerous e-cigarette and e-liquid brands available in South Africa seemingly tap into a hip younger crowd using images and fonts on packaging design similar to the styles used in graffiti and comic-book art.
The e-liquids sold by Twisp, South Africa’s leading e-cigarette brand which was recently acquired by British American Tobacco (BAT), use vibrant colour and sublime renderings of their fruity and dessert-flavoured e-liquids. There are mouth-watering descriptions; for example consider the e-liquid called Love Fool which contains 18mg nicotine. It encourages the user to, “Succumb to the irresistible, sweet temptation of cotton candy, marshmallow, caramelised sugar and a seductive sprinkling of crushed coconut biscuit.”
Although stores and websites include age restrictions for under-18s as a nod to their intended adult audience, this is not a deterrent. As 17-year old Kyle says, “We get someone over 18 to buy for us”, which mirrors UK research that indicates more than half of regular youth vapers ask someone else to buy a device or refills from a shop.
The 95% healthier flaw
Most vaping brands and stores punt the fact that their products are healthier than tobacco cigarettes, with many quoting a figure of 95%. Given the propensity for young people to use e-cigarette websites as their go-to for information as evidenced in Mhazo’s focus groups, this is problematic.
This percentage was somewhat controversially endorsed by Public Health England, an agency of the UK Department of Health, following a research report developed in 2013 that estimated the harms of 12 nicotine-containing products. The report, Estimating the Harms of Nicotine-Containing Products Using the MCDA Approach was compiled following a two-day workshop of 12 panellists using a multi-criteria decision analysis. Both The Lancet and BMJ (British Medical Journal) criticised the report due to its limitations (a lack of data and panellists’ conflicts of interest), with The Lancet describing it as “methodologically weak”.
Ilona Jaspers, a US professor of paediatrics, microbiology and immunology at the University of North Carolina, believes that both scientists and policymakers should stop comparing vaping outcomes to smoking outcomes. Referencing EVALI in particular she says: “The clinical manifestations in these patients are not something a doctor would ever see in somebody who has been smoking cigarettes for a few months.”
Quite simply, no long-term data exists yet to understand the implications of e-cigarettes and e-liquids. These are fast-evolving consumer products with new mixtures having as yet unknown effects on humans. Evidence emerging in medical journals is beginning to raise warning signals about toxins in some e-liquids that can cause lung damage, and mixtures that may damage human blood vessel cells, potentially increasing the risk for cardiovascular disease.
The ticking of time in the abyss
In South Africa it is anticipated that e-cigarettes will soon be regulated by a reworked piece of proposed legislation called the Control of Tobacco Products and Electronic Delivery Systems Bill. Here, the term “electronic nicotine delivery system” is specifically defined as “an electronically operated product designed to deliver an aerosol to users by heating a solution comprised of nicotine and typically, but not necessarily, propylene glycol, glycerol or both, and often flavouring and any other solution intended for use with or in the product”. Accordingly, e-cigarettes fall within the ambit of the term “electronic nicotine delivery system”.
The bill will further regulate the advertising, promotion, sponsorship, distribution and display of electronic delivery systems, their packaging and labelling, and the standards for their manufacture and importation.
Although currently before parliament, it is unclear when the bill will be legislated. Zanele Mthembu says a reasonable expectation is within a year or two, given the painstaking scrutiny it must undergo in light of a sustained pushback against its adoption by tobacco companies and the smoking lobby.
But time is of the essence in terms of its swift adoption given that e-cigarette makers are exploiting the protracted process and the current free-for-all market conditions. Local sellers will continue to market e-cigarette products with impunity, further entrenching e-cigarettes as an on-trend leisure activity. Multinational players will drive hard their e-cigarette campaigns in South Africa. PMSA’s IQOS strategy will continue to deepen the dialogue – not the campaign – drawing potential users through intimate gatherings that leverage aspirational media platforms and feature local celebrities who are “disruptors” in diverse creative fields from technology to fashion design.
BAT will continue to ride the wave of exponential growth in the South African vaping market with their local poster child, Twisp, which generates more than 50 000 consumer interactions each month. With an eye on the continent, BAT anticipates Twisp to open the way for switching 70 million (adult) African smokers to their e-cigarette products.
Within these strategies, e-cigarette marketers may shrug at the prospect of under-age vaping: their products, they say, are aimed at adults. But in the blissful unregulated abyss, young South Africans continue to inhale the compelling words and images of e-cigarette marketers with little thought to potential risk, embedding habits and brand loyalties that guarantee – for marketers – a convenient vaping future.
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Annually, the World Health Organization (WHO) drives initiatives on May 31 as World No Tobacco Day. The annual event highlights the health risks associated with tobacco use and exposure by – advocating governments to draft effective policies that aid reduction of tobacco consumption, decreasing children’s exposure to secondhand smoke (SHS), and encourage cessation and tobacco control policy.
This year’s theme “Protecting youth from industry manipulation and preventing them from tobacco and nicotine use” focuses on empowering young people to engage in the fight against Big Tobacco.