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Few topics in tobacco control have been more hotly debated in the past several years than electronic cigarettes (e-cigarettes) or electronic nicotine delivery systems (ENDS). Advocates claim that the devices, which use battery power to aerosolize nicotine into a chemical propellant, offer significant harm reduction because they do not create the carcinogenic combustion products found in conventional paper cigarettes.1,2 Critics, meanwhile, point to a host of concerns regarding the unproven health claims and questionable advertising tactics by e-cigarette companies as reasons for greater regulation of these products. While health departments and researchers try to collect data on these issues, the use of ENDS has increased substantially globally, with a 2014 World Health Organization (WHO) survey suggesting that more than half the world’s population resides in countries where ENDS are available for purchase.3The growing market was valued at an estimated US $3 billion in 2013, with projections estimated to reach $10 billion by 2017.3,4 The availability of ENDS extends not just to wealthy nations but also to low- and middle-income countries (LMICs) because the devices can now be made more inexpensively.
In response to the increasing availability of ENDS, WHO released a report on October 2014 through the Framework Convention on Tobacco Control encouraging stronger control measures on the manufacture and sale of these products.3 In particular, the report proposed stronger restrictions on advertisements to avoid attracting youth and never smokers, along with a ban on ENDS use in public spaces. In this Viewpoint, we report and highlight additional health considerations of e-cigarettes unique to the LMIC setting.
E-cigarette supporters have defended ENDS not only as a harm reduction measure but also as a smoking cessation aid potentially superior to existing products.2 This assertion is problematic for several reasons. First, data supporting the effectiveness of e-cigarettes at helping smokers quit are lacking, with randomized clinical trials finding no significant difference in tobacco quit rates between patients who used ENDS with nicotine and those who used placebo.1 Second, the argument that ENDS manufacturers sell e-cigarettes solely as a smoking cessation tool is not supported by their marketing, which often appears geared toward minors and never smokers. Nicotine cartridges are sold in a variety of youth-appealing flavors such as fruit, candy, and cola.1
Furthermore, ENDS manufacturers have falsely promoted their products as a safe alternative to smoking because these products do not rely on high-temperature combustion like paper cigarettes. Emerging data, however, demonstrate that the propellants used in these devices, such as propylene glycol or glycerines, decompose into known carcinogens, such as formaldehyde and acetone, when aerosolized.1,2Much like conventional cigarettes, e-cigarettes also produce secondhand vapors, which can be inhaled by bystanders and are of unknown health significance. Moreover, nicotine is an incredibly addictive substance with potentially harmful vascular and neurologic properties.1 There is also limited research investigating the toxins released by the hundreds of flavoring additives used in e-cigarette nicotine cartridges.1
The advent of ENDS has also created new health problems. For example, some products have refillable tanks or cartridges in which nicotine-infused “e-fluids” can be replaced or mixed to customize the “vaping” experience.2 These fluids have resulted in a substantial increase in reported unintentional overdoses, likely among children, who could confuse flavored e-fluids containers for soft drinks or juices.3,5
PROBLEMS SPECIFIC TO DEVELOPING COUNTRIES
Eighty-four percent of the world’s smokers live in LMICs.6 Tobacco products contribute to both communicable and noncommunicable diseases, amplifying the dual burden of disease in poor countries unprepared to devote limited resources to epidemics of both types. Due to the seeming technological complexity of ENDS, it is a common misconception that e-cigarettes are a problem relevant only to high-income countries. Public knowledge of these devices is already high in LMICs. For example, the results of the recent International Tobacco Control survey study estimated that there was substantial awareness about ENDS among adults, estimated to be 34% in Mexico, 35% in Brazil, and 62% in Malaysia.7 E-cigarette use was estimated to be as high as 19% in Malaysia.7 Tobacco exposure contributes to some of the leading causes of death in low-income nations (such as lower respiratory tract illnesses and tuberculosis)6 and also contributes to cancer and ischemic heart disease, which are increasing as causes of death in the developing world.
The health effects of ENDS can stress LMIC health systems relatively more than health systems in high-income countries. Patients in LMICs contract and die of noncommunicable diseases at a younger age than patients in high-income countries, causing greater economic stress on families.6 Harms unique to ENDS such as unintentional ingestion of refillable nicotine fluids are magnified in rural settings where access to emergency medical services is limited. Uncontrolled population growth of cities in many LMICs also introduces the variables of air pollution and crowded urban living conditions, amplifying the potential secondhand vapor exposure. Governments with high levels of corruption or poor law enforcement capabilities cannot execute control and regulation of both legal and illegal markets of tobacco and ENDS products.7
THE ROLE OF THE TOBACCO INDUSTRY
The tobacco industry, possibly in response to declining sales of conventional cigarettes, has turned its attention to e-cigarettes in the past year. The largest firms have already purchased many of the smaller e-cigarette companies, whereas others are creating new goods to compete in this market segment.1,2 This development is concerning because the industry has a proven record of hijacking harm-reduction strategies to better their public relations image while finding novel ways of attracting new smokers.8 A recent review2 suggests a disturbing potential scenario in which this could take place in poor countries: tobacco companies could use inexpensive e-cigarettes to entice new smokers, then increase the price of these products to make them unaffordable, in essence encouraging users to switch to conventional cigarettes. The historic use of such tactics is well documented in LMICs, where never-smoker engagement campaigns—such as the sale of single cigarettes or absorption of financial losses on discounted cigarettes to attract minors and young people—have been observed.8 Technology-interested youth in LMICs are most likely to adopt e-cigarette smoking behaviors, making them an attractive target for recruitment. Multinational monopolies have the economies of scale to make ENDS less expensive and thus more available in developing countries. A recent exposé of the US Chamber of Commerce revealed hidden global tobacco lobbying to promote and enable tobacco use among poor populations in Nepal, Jamaica, Uruguay, Moldova, the Philippines, and El Salvador.9
THE GLOBAL RESPONSE TO E-CIGARETTES
The legal control of ENDS has proven problematic for many countries because of the unclear classification of these products as consumer goods, controlled substances, or medical devices. Further complicating the issue, vaporizers can be sold separately from the nicotine cartridges and fluids, evading regulation as tobacco products.2Currently, ENDS are banned in their entirety in Brazil, Uruguay, Singapore, and the Seychelles.3 Other countries have banned e-fluids, restricted advertisement, or taxed the devices heavily, but enforcement is likely to be variable. Notably absent from the list of nations banning ENDS is China, home to 300 million smokers.4 How the Chinese government approaches this issue will be of great interest to global health authorities because if even a small fraction of the nation’s smokers were to adopt e-cigarette use, the number of users would be considerable. Access to ENDS in China is an open door, as 95% of the world’s e-cigarettes are manufactured in the country, and there are reports that the state-owned China National Tobacco Corporation intends to produce its own line of e-cigarettes for sale.4,7
Developing nations should not underestimate the availability and targeted marketing of ENDS within their borders and should place e-cigarettes under the purview of their medical and pharmaceutical regulatory boards. Low- and middle-income countries can feel empowered to exclude multinational tobacco companies from this regulatory process in accordance with Article 5.3 of WHO’s Framework Convention on Tobacco Control, which warns against the conflict of interest posed by the industry in this sphere.3 International nongovernmental organizations such as the Gates Foundation and the Bloomberg Initiative to Reduce Tobacco Use should support these efforts to provide consistency in control and enforcement of ENDS legislation. Even though e-cigarettes may have a future as smoking cessation tools, evidence to support this indication is lacking. More rigorous studies must be conducted regarding the awareness, usage patterns, and potential for harm of these devices in low-income countries, particularly Africa and South Asia, where data are currently missing.