Will South Africa’s new vaping laws lead to more smokers instead of fewer?

Parliament’s portfolio committee on health has called for more research on how the health risks of e-cigarettes and conventional smoking compare, to get a better grip on South Africa’s relatively controversial new tobacco bill. 

If the bill is passed, e-cigarettes will be seen as tobacco products, which will mean that vapers won’t be able to puff in public spaces, ads for these e-devices will be banned and the health minister will say how the packaging and labelling of the products should look. 

The committee’s concerns were raised in a report on the bill’s public consultations that the legislation doesn’t distinguish between e-cigarettes and more conventional tobacco products or considers claims that vapes could be used as tools to help smokers quit.

In 2021, almost 30% of South Africans older than 15 used tobacco products, including e-cigarettes. That same year, about 42,000 people died of tobacco-related diseases like cancer and heart and lung problems in the country.

Having signed the World Health Organisation’s (WHO’s) anti-tobacco agreement, called the Framework Convention for Tobacco Control, South Africa must have rules in place so that smokers are encouraged to quit their habit and young people aren’t tempted to start, to clamp down on tobacco use — what the WHO calls “one of the biggest public health threats the world has ever faced”. 

But will treating vapes like smokes get more people to quit tobacco — or more people to start? We look at what the evidence shows.

To vape, or not to vape

In a conventional cigarette, the smoke from burning tobacco, which releases nicotine and a mix of other chemicals, is inhaled. With an e-cigarette, a user breathes in vapour formed when a flavoured liquid, which usually contains nicotine, is heated through a battery-powered circuit. 

Because vapes don’t produce smoke from burning tobacco, they’re often punted as less harmful than smoking and seen as a popular way to help people quit. 

But they aren’t risk free — especially for people who have never smoked. 

Inhaling vapours from these liquids can cause lung damage, heart problems and fertility issues possibly linked to the type of chemicals and also nicotine in the mix. Moreover, nicotine — the chemical that gets you hooked — can be a gateway for kids to start smoking and a study from the US showed that, in fact, fewer people successfully quit smoking with the help of e-cigarettes than when they used medicine to help them stop. 

The evidence on the health effects of electronic cigarettes “is still sparse and sometimes contradictory”, says Estelle Dauchy, principal research officer at the Research Unit on the Economics of Excisable Products (Reep) at the University of Cape Town.

“The uncertainty around the long-term health effects of vapes is particularly concerning and it is precisely why the WHO recommends a precautionary approach.”

Trading clouds for cigs

There are different ways to skin this particular Schrödinger’s cat. 

For example, in New Zealand, Canada and the UK vapes can’t be sold to someone under 18 and in Australia you can only buy e-cigarettes at a pharmacy.

Similar to what is proposed in South Africa’s tobacco bill, many countries, such as Denmark and Finland, require on-pack warnings about specifically nicotine being addictive and have banned ads for e-cigarettes in newspapers, magazines and on TV. Elsewhere, such as in the US, authorities have clamped down on or outright banned fruity-flavoured vapes, and many countries, including Portugal, Germany and the Philippines, charge a sin tax on e-cigarettes, seeing that it’s been proved as one of the best forms of tobacco control. (Sin tax is a levy usually raised on harmful substances like alcohol and tobacco, to deter demand for these products.)

In June last year, South Africa instituted such a tax on vapes. 

But making it harder or more expensive for people to get one kind of fix can push them towards another, some studies show. 

This is because of something economists call cross-price elasticity, which means that if one type of good — vapes in this case — becomes more expensive and so deters people from buying it, they will likely choose another, similar product — in this case, cigarettes — at a lower price. In this way, vapes and cigarettes become substitutes.

Models based on US data on smoking and vaping from 2011 to 2018 show how this principle is likely to play out in real life. A tax hike of $1 on conventional cigarettes would lead to significantly fewer people smoking but more choosing to vape. Similarly, when tax on e-cigarettes was upped by the same amount, people would swap their vapes for old-school smokes. Putting their results together, the researchers found that a 2020 proposal to tax each millilitre of vaping liquid at $1.65 would translate to 2.5-million more cigarette smokers in the US.

The effect seems to hold in teen use too, when researchers looked at data that tracked US high school students’ smoking and vaping habits between 2014 and 2019. The analysis shows that with an extra $1 in tax levied on vapes, just over two-thirds of the kids who dropped e-cigarettes would turn to smoking at least half a pack of conventional cigarettes a day. 

“If access to one product is blocked due to a price increase, some people may choose to quit and buy nothing, or [they may choose to] switch to another product,” says Michael Pesko, co-author of the study and an e-cigarette policy expert from the University of Missouri. 

Death and taxes

Though South Africa does tax e-cigarettes, researchers at Reep say it does little to stop young people from sneaking a puff.

For example, the price of a popular 3ml disposable, single-use vape (which kids think are cooler than devices with a refillable tank) increased by just R10 after the tax was implemented last June. In contrast, the price of a 100ml container of e-liquid for refilling a vape tank more than doubled (from R280 to R613.50). So, if only price is considered, the tax would likely not make single-use vapers quit. 

And cigarettes may still be an attractive option too. 

Puff for puff, vapes and old-school cigarettes cost about the same. A packet of 20 cigarettes sells for about R30, which works out to R1.50 per stick. On average, a smoker gets 11 puffs per cigarette, research shows. 

At around R105, a vape pen filled with 3ml liquid can give you between 600 and 800 puffs, online ads say. So, to get the same number of draws of your nicotine fix from conventional cigarettes, you’d have to buy about three packs and a few loose draws, which would cost somewhere between R90 and R105 too.

Dauchy says there isn’t much local research on the impact of the e-cigarette tax yet and that though there’s evidence of substitution between vapes and cigarettes, most of these studies use data from specific user groups in the US, so they don’t necessarily apply to South Africa. Moreover, the types of products available also affect the outcome of such research, especially with something like e-cigarettes, for which there are many varieties.

She notes: “Policymakers should be aware of these studies, but they need to do a country-specific study of the e-cigarette market at the national level before a bill is passed.” 

Licence to vape

Other restrictions that limit people’s access to vapes may also lead to their being swapped for cigarettes. 

In San Francisco, for example, bans on all flavoured tobacco products, except for mint and menthol, were announced in July 2018. (Big Tobacco has been known to use flavoured products to target young people.) A study in JAMA Paediatrics showed that, based on data from shortly after the ban was announced, the odds of underage cigarette smoking more than doubled, though the conclusion from the analysis was less dramatic after the results had to be adjusted because the data came from a period when there were no penalties yet for breaking the no-flavours rule. 

Despite this blotch, another study, among 18- to 34-year-olds and conducted 10 months after the ban was put in place, showed that vape use dropped by eight to 12 percentage points — but cigarette smoking was up by 10 points among 18- to 24-year-olds. 

Dauchy says that though there’s evidence of vapers switching to traditional cigarettes shortly after the regulations were passed, it’s unclear how long the effect holds. 

“What about one year from now? How about three?” she asks. 

“There isn’t enough evidence on the long-term effects of these laws for us to come to a conclusion. People will always find a way to get their hands on illegal products, but [putting age restrictions in place] does make it harder for children to access. That’s the important part.”

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.