Vaping, which is gaining popularity as a lifestyle trend and is an alternative to conventional smoking in what is an $80 million industry in South Africa, is not without its risks.

It has gathered steam over the last decade to become one of the most recognizable social gadgets. The mass appeal transcends age, culture and gender. From advances around Artificial Intelligence (AI) to medical explorations, handheld vaping devices have become one of the quintessential symbols of the digital era.

Vape stores have become a standard feature of every shopping precinct, whether large or small, in the upmarket areas of South Africa. The stores are as recognizable as retailers that have been around for decades and have etched themselves in the minds of consumers.

During its relatively short period in the space of consumer consumption, it has amassed polarizing views – primarily related to cost, exposure and health. Here are some of them:

Vaping to quit smoking

Various strategies have been used to market e-cigarettes, but none is more prevalent than the idea that they assist smokers to kick the habit.

Vapour Products Association of South Africa (VPASA) CEO Zodwa Velleman says electronic vaping has provided users an alternative that has been beneficial for their health as a result of quitting traditional cigarettes.

However, head of the Lung Clinical Research Unit at the University of Cape Town, Associate Professor Richard van Zyl-Smit, says the appeal of electronic vaping products (EVPs) is in the skewed manner in which it is marketed.

He says it appeals to the senses of those who weren’t smokers to begin with.

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“The attraction should be for those who are smoking and can’t give up the habit, to switch to something that is potentially safer. However, what has occurred is that the marketing comes across as trendy and as something you should be doing. So, non-smokers, those who wouldn’t have started smoking, are getting involved with vaping and are seeing it as a safe activity.”

“The appeal should be from a tobacco perspective. [It should] not be appealing to the non-vaper [and] non-smoker,” Van Zyl-Smit says.

Velleman says she cannot dismiss the claim that there would be interest from individuals who were not previous smokers but this would be a small percentage compared to former smokers who have completely switched from traditional cigarettes to vaping.

She says a study conducted by global management consulting firm Canback Consulting found that, “the people who try e-cigarettes are less than 0.1% and that is not the bulk of the users. The bulk of the users are your historic traditional smokers. So, you can say that 99% [of EVP users] are people that were smokers”.

Executive Manager at Vape King in South Africa, Sharri Van Zyl, observes that those who initially take up vaping use it as a means, “to get off cigarettes and then adopt it as a lifestyle later on”.

Founded in 2012, Vape King is one of the few recognizable e-cigarette retailers in an industry that is currently worth R1.1 billion ($80.4 million) in South Africa. A majority of the vaping stores operating in South Africa are “moms and pops corner shops”, according to Velleman.

These are small shops that are owned and run by families who are not commercially recognizable brands, she says.

Van Zyl-Smit says the assertion that vaping leads to the quitting of traditional cigarettes, which contain carcinogens that cause cancer, is tenuous. He says he would not encourage smokers to take up vaping to quit cigarettes.

“When one looks at vaping as an option to quit smoking, the data is unfortunately very poor. It has helped some people. And certainly, if you look on the internet…there will be some people who tell you, ‘I smoked for 20 years and I quit. It’s the best thing ever’.

“One person, unfortunately, from a scientific point of view, does not make a study.

“It’s not to say they [e-cigarettes] won’t help an individual. But if we, as a community of people, who are looking after smokers, are saying, ‘what are the best options?’. Vaping is way down the list of best options to help you quit.”

While 32-year-old Kim Salinger (not her real name), who has been vaping for two years, says it helped her quit smoking, she says her initial plan was to “not smoke anything but I’m still vaping”.

Associate Professor Richard van Zyl-Smit, says the appeal of electronic vaping products (EVPs) is in the skewed manner in which it is marketed. Picture: Motlabana Monnakgotla

“It makes me feel like it’s not such a bad habit. Also, now, is a habit that’s with me wherever I go.”

She says she eventually intends to quit.

This may prove to be challenging because of the physical and psychological effects EVPs have on the body, Van Zyl-Smit says.

“There’s no question that vaping is addictive. Both tobacco cigarettes and vape liquids contain nicotine. There are a few nicotine-free vape liquids, but a majority of them contain nicotine.

“Nicotine is the substance that causes the physical chemical addiction.

“There is also the behavioral element, that when you’re feeling anxious or angry, you grab a cigarette. And similarly, because vaping has that same mechanism whereby, ‘I respond to my environment… by grabbing a vaping device’, bringing it to your mouth, inhaling and getting a positive feedback.

“So, it becomes both a chemical addiction and a habit. Both of them link together. Even if you take, nicotine-free vape, you will still become addicted because of the habit element, and to necessarily the chemical addiction. Which, is more important when trying to give up [a habit],” Van Zyl-Smit says.

Despite the varying insights, all parties seemingly spoke with the same breath – but for different reasons, saying that vaping was still in its infancy and more research was being conducted.

Health risks versus health benefits

The consensus on the hazardous effects of traditional cigarettes is unanimous across all spectrums. Not so much with e-cigarettes, although there have been reports that claim their flavorants have adverse effects on the respiratory system. The most prominent being bronchiolitis obliterans, commonly referred to as ‘popcorn lung’.

“It is a condition that damages your lungs’ smallest airways and makes you cough and feel short of breath. It’s sometimes caused by breathing in a chemical used to flavor microwave popcorn. But other chemicals or lung illnesses can also cause popcorn lung,” webMD writes.

The chemical called diacetyl in the popcorn flavorant that causes this illness has previously been used in some vapor liquids.

Salinger, who emphasizes that she does not enjoy the sweeter vape flavors and has “defaulted to the mint”, says she has read a fair amount about popcorn lung and is personally concerned about it but also commends the improvements to her health since she started vaping.

“I’ve seen improvements in my health, my breathing, my skin since I stopped smoking cigarettes. But there are still other problems which are attributed to vaping,” Salinger says.

Van Zyl-Smit says the question of the adverse health effects of vaping needs be viewed from two perspectives – the smoker and the non-smoker’s perspective.

From a non-smoking point of view, research has been conducted, “showing that if you expose people and animal cells to vaping liquid, you can induce a whole lot of changes that look similar to what would happen if you exposed them to cigarettes”.

“And so there is data to show that if you are vaping, you may have increased risks for viral infections, for pneumonia… it may increase your risk for TB [tuberculosis].”

“There are a whole lot of small experiments showing that if you vape, there are definitely biological factors that may cause problems.”

From a smoking point of view, Van Zyl-Smit says: “If you are smoking and you switch to vaping, your risk for infections and cancer seems to be reduced. But to what extent, we haven’t seen dramatically at this particular point.”

Velleman contends that there are other alternative views from the medical fraternity. She says Dr Konstantinos Farsalinos, who has “done the most amount of research on vaping and its impact on health”, has a different assessment.

She says Farsalinos, who is a doctor at the Onassis Cardiac Surgery Centre in Greece, spoke at a conference hosted by VPASA.

“He says one of the challenges that we face is the product that had been used by the [popcorn] manufacturer was used by some of the people who manufacture the [vaping] liquids that are used in e-cigarettes,” Velleman says.

“If you look at the products that go into the making of the liquid – that product is longer there. It’s actually been banned and is not allowed to be used.”

Velleman says these incidents occurred during the earlier phase of the establishment of the industry, “because it has always been an industry in evolution”.

The health challenges presented by popcorn lung in the vaping industry were “identified and dealt with”, she says.

Another concern about flavors is that spices used in vaping liquid contains food flavorants. “The same types of flavors that are being heated to several hundred degrees and are being inhaled. We just don’t have enough data to suggest what happens to the so-called safe flavorants when they are heated and inhaled,” Van Zyl-Smit says.

As EVP products find their way into social dialogues, the discussions span beyond recreational use, or as a tool to quit smoking. There are theories that, with enough exploration, the devices might be used to dispense medication.

The idea is that oral medications and hypodermic needles would be replaced by EVPs, which, in theory, would absorb the medication directly into the bloodstream. The health benefit being that the elimination of needles could prevent mishaps such as overdoses, as well as, HIV and hepatitis.

As it stands, it has been widely reported that medical marijuana is being used via EVPs by patients, as part of pain management therapy for illnesses such as cancer.

A widely-used inhalant in the medical fraternity is the asthma inhaler and, most recently, the insulin inhaler. Both do not require heat to dispense medication.

“Conceptually, inhaling medication or drugs is a very attractive idea,” Van Zyl-Smit says.

“The two problems that occur are that the vaping device itself heats up hugely. The way it turns the water into vapor is that it’s boiled to several hundred degrees, which changes the chemical constituents.”

“You cannot put a vaccine or an antibiotic in it because at two-three hundred degrees, it would completely destroy whatever’s in it. So, the heating part is not suitable for a majority of drug delivery.

VPASA CEO Zodwa Velleman says electronic vaping has provided users an alternative that has been beneficial for their health as a result of quitting traditional cigarettes.
Picture: Motlabana Monnakgotla

“The second element is that inhaling drugs may be a good way of delivering them, but you have to make sure that you aren’t damaging the lungs.”

Van Zyl-Smit says the difference between taking pills, injections and inhaling medication is that the tablets are purified by enzymes while in the stomach. For injections, there is a stringent regulatory process where it has to be proven that the environment is sterile and there is no contamination.

“Similarly, if you were going to create an inhaled drug, you would need to be absolutely certain that it only went into the lungs. It went where it was supposed to and didn’t cause problems during the administration period.”

Tobacco regulations

Laws and regulations around the vaping industry remain unclear primarily because it’s a relatively young industry, particularly on the African continent.

Another view all parties – from the medical industry, the consumers, the retailers as well as the VPA – were all unanimous on.

However, the parameters of the laws and regulations are a matter of contention.

Another view all parties held was that traditional cigarettes were hazardous. More than 42,100 South Africans are killed by tobacco-related illnesses each year, equivalent to about 10.1% of the nation’s deaths, according to Tobacco Atlas.

“Complacency in the face of the tobacco epidemic insulates the tobacco industry in South Africa and ensures that tobacco’s death toll will grow every year,” the report states.

So, in a bid to clamp down on cigarettes, last year, the South African parliament, led by health minister Aaron Motsoaledi, tabled a bill called the Control of Tobacco Products and Electronic Delivery Systems Draft Bill.

The bill, which awaits final approval pending public views, will ultimately replace the tobacco control legislation of 1993. It seeks to “provide for control over smoking; to regulate the sale and advertising of tobacco products and electronic delivery systems,” the bill states.

The term ‘smoking’ is the point of contention as defined by the bill which states that inhaling, exhaling or holding “control over an ignited tobacco product or a heated, but not ignited, tobacco product that produces an emission of any sort”.

Simply put, both users of traditional cigarettes and EVPs will be indiscriminately affected by the bill.

The bill, among other stipulations, proposes the following: To regulate the sale and advertising of tobacco products and electronic delivery systems; to regulate the packaging and appearance of tobacco products and electronic delivery systems; to prohibit the free distribution of tobacco products and electronic delivery systems; to prohibit the sale of tobacco products and electronic delivery systems by means of vending machines.

A by-product of the conditions above is that: retailers will be required to stop displaying packages of cigarettes and EVPs in full view of customers and that packaging would be uniform for all brands to reduce the appeal of tobacco products; a ban on indoor smoking would be imposed, meaning no more smoking areas in social spaces such as restaurants, bars and vape stores; more detailed regulations on EVPs as they contain nicotine which the proposed bill states is a “highly addictive and toxic substance”.

Salinger, who is a former cigarette smoker, embraces the proposed bill and says, “I think it’s great. Even though I’m an ex-smoker, I hate the smell of cigarettes. I think it’s very inconsiderate when people smoke around others.”

“I wouldn’t mind going outside to vape. But if it [the bill] would stop people from smoking cigarettes around kids and other people then, I’d be happy to see that.”

Vape King’s Van Zyl, who says her outlet is part of the VPASA, is aware of the proposed bill and says there is still uncertainty around how the regulations will be implemented, but the proposal to have the packaging in white and change store displays will definitely affect them.

“Regulation is definitely needed in terms of the standard in the way liquids are mixed, and selling to underage people.”

She says she agrees with regulations especially as it relates to the appropriate age of users and vaping in public but there’s a limit to a bill that would prevent users from vaping inside vape stores.

“To me, personally, it does not make sense. It’s like saying you can’t drink alcohol in a bar.”

The Vape King store in Benoni, which is in the East Rand of Johannesburg, is in a small shopping complex in an area that FORBES AFRICA observed to be quiet and unassuming. But the store itself is a subject of curiosity because in the short amount of time we spent in the store, there was a great deal of foot traffic from customers, young and old.

Employees at the store say there is a diverse demographic of customers who walk in and out daily and are particular about the kind of vaping experience they prefer.

“We sell to customers who are aged 18 and upwards, and based on what the customers are looking for, we are able to provide them with what they need,” says store manager Michelle Milne.

Louis Badenhorst, who works alongside her, says the variation in devices is what sets each experience apart.

“You do get customers of all ages who want to supplement, and you get a lot of young people,” he says alluding to the preference in devices.

Louis Badenhorst, who works at Vape King, says the variation in devices is what sets each experience apart.
Picture: Motlabana Monnakgotla

On regulating, Velleman says the VPA has collated more than 10,000 views from the public and feels that the bill, which was closed for public comment in August 2018, should consult the public again, “for a second round”. And that, moving forward, the VPASA will be guided by the Department of Health on how to proceed, based on the public comments the organization has gathered.

She also says that there should be differences in regulation regarding vaping and combustible cigarettes because the e-cigarette is renowned for its “safer features”. She says the approach from government is based on research that shows the absolute harm of smoking.

“We are saying the e-cigarette is new to the market and is innovative.”

“We would like the government to consider the research that has been done. As the association, we collated all the information that is available, we have summarized it and we have said that our arguments are based on these pieces of evidence.”

“If there is something that we must include or something that we have misinterpreted for our own benefit, let there be discussions so that we are able to create the best regulations for the industry.”

There is no doubt that the public’s relationship with smoking will change dramatically in the foreseeable future. Whether the scales tip on the side of the medical industry or on the vaping industry, it remains to be seen.

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