In a recent article on the risk factors and perceptions of e-cigarettes in South Africa, researchers led by Mageshree Naidoo concluded that e-cigarettes could cause harm to both users and non-users, and public health would be improved if these products were not available. This conclusion ignores the growing scientific evidence that e-cigarettes are less harmful than traditional cigarettes and offer smokers, including the millions of smokers in South Africa, a tool that will help them quit using combustible tobacco products.
The Foundation for a Smoke-Free World conducted its Global State of Smoking Poll in South Africa in 2019 and found that among South Africans smokers who are aware of e-cigarettes but do not use them, the percentage who believe e-cigarettes are less harmful than combustible cigarettes declined from 39.9% in 2017 to 33.6% in 2019. This misperception was reflected in Naidoo’s study. When questioned, 74% of e-cigarette users in the study believed that e-cigarettes negatively impacted their health and 87% cited personal health as the reason why they wanted to stop using them. The investigators did not question participants about the relative risk of e-cigarettes compared to combustible cigarettes, so the study results suggest that users believe that e-cigarettes alone are harmful.
Large public health entities have reviewed the evidence on e-cigarettes and concluded that e-cigarettes are less harmful than combustible cigarettes, with the short-term health risks of e-cigarettes being substantially less than the risks of combustible cigarettes. The long-term health effects are still largely unknown because of the relatively short time e-cigarettes have been on the market; but recent studies suggest that long-term e-cigarette use may alleviate some of the health burdens of tobacco smoking, such as associated conditions like COPD. If we move smokers down the continuum of risk, away from harmful tobacco products like combustible cigarettes and towards safer nicotine alternatives, millions of lives will be saved.
The recent Cochrane Review looked at a number of studies on the use of e-cigarettes to help people stop smoking and concluded that there is “moderate certainty evidence” that nicotine-containing e-cigarettes help more people quit smoking than e-cigarettes without nicotine and nicotine replacement therapies. Because studies have also revealed that risk perception influences smokers’ decisions to quit or switch to tobacco products with lower risk profiles, the authors’ messaging that e-cigarettes are harmful is dangerous and drives smokers who want to quit or switch to safer alternatives away from reduced-risk products.
Naidoo’s study sample size is small, with just 188 e-cigarette using adults. Its convenience sampling design is biased and does not reflect the reality of tobacco use in South Africa. Because of this, we consider the sample biased and improbable and the results cannot be used to extrapolate public health outcomes in South Africa.
Eighty percent of the world’s 1.1 billion tobacco smokers live in low- or middle-income countries such as South Africa. Many of these countries are enacting restrictive policies against e-cigarettes based on misinformation. These policies and misperceptions are blocking access to potentially life-saving technologies for smokers, especially smokers who wish to quit but may be unable to do so through other methods. Because tobacco smoking is the leading cause of preventable death and disease, we must do everything we can to save lives by supporting all harm reduction strategies, including e-cigarettes, and supporting everyone’s rights to attain their highest level of health, have access to factual information, and make their own choice.