Regulate E-cigarettes to protect health

By Dr Poonam Khetrapal Singh, WHO Regional Director for South-East Asia

In recent years the electronic cigarette (e-cigarette) industry has been rapidly expanding, evolving from just one manufacturer in 2005 to a US $3 billion global business with 466 brands. Electronic nicotine delivery systems (ENDS), of which e-cigarettes are the most common prototype, are battery-powered devices that use electricity to aerosolize a nicotine containing fluid for inhalation. We know that nicotine is addictive and is not harmless. But as ENDS are not made from tobacco leaves, they have largely escaped any regulation. The rapid global growth of ENDS represents an evolving frontier filled with both promise and threat for tobacco control. There is an urgent need to regulate the use of ENDS to maximize their potential and minimize health threats.

ENDS are frequently marketed by the industry as an aid to quit smoking or a healthier alternative to tobacco. The argument for ENDS is that they don’t contain the toxic byproducts found in cigarettes, such as tar, and don’t produce smoke. But the fact is that there is very little research on ENDS and no convincing evidence that they are effective as a “quit smoking device”. In fact, with almost 8 000 different flavours added, including fruit and candy-like flavours, there is legitimate concern that instead of reducing the number of smokers, they will actually serve as a gateway to nicotine addiction, and ultimately, smoking, particularly for young people. The evidence supports this—experimentation with e-cigarettes is increasing rapidly among adolescents, doubling from 2008 to 2012.

Existing evidence shows ENDS aerosol is not merely “water vapour”. It contains cancer-causing agents, such as formaldehyde, which in some brands reach concentrations close to that of some conventional cigarettes. They deliver nicotine, which we know is a potent vasoconstrictor that may contribute to cardiovascular disease. There is sufficient evidence to show that nicotine itself, and not just the smoke from cigarettes, can affect brain development in fetuses and adolescents just from passive inhalation. ENDS contain varying levels of nicotine. Frequently, these levels are similar to that in cigarettes, and without regulation there is no way to control this amount. There is also evidence that ENDS use indoors increases second-hand exposure of non-smokers and bystanders to nicotine and a number of toxicants. While some evidence does show that ENDS are likely to be less toxic than conventional cigarettes, it is not known how much less toxic they are. Until we have sufficient evidence to determine the extent of their health impacts, the industry must be regulated. If we wait to implement regulations until the research is available, it may be too late.

While some steps have been taken to regulate ENDS, there are huge variations in country policies. Singapore and Brazil have completely banned E-cigarettes. In the WHO South-East Asia Region, many countries are considering implementing regulations. In India, a governmental round table discussion in July decided to consider banning ENDS. While these are steps in the right direction, several countries in the developing world have no regulations or measures to regulate E-cigarettes.

It is for this reason that WHO recently released a Report on the Regulation of ENDS, which will be the primary topic of discussion at the Sixth Session of the Conference of the Parties to Framework Convention on Tobacco Control (FCTC), to be held on 13-18 October 2014, in Moscow. In the report, WHO calls for regulations to prohibit addition of flavours which may make ENDS more attractive to youth, ban the use of ENDS indoors and in public and workplaces and restrict its advertising, promotion, and sponsorship to ensure that adolescents and non-smokers are not targeted. The regulations should impede ENDS promotion to non-smokers and young people, minimize potential health risks to both users and non-users, prohibit the dissemination of unproven health claims, and protect existing tobacco control efforts.

WHO is urging countries to choose the best regulatory framework available to implement the suggested regulatory objectives. In some cases, this might be the existing tobacco control legislation, or the existing medicines and medical devices regulations, while in other cases it may be in other government sectors. Regardless, the regulations must be implemented in a timely manner to protect the public from any potential ill-harm while more tests regards the health impacts of ENDS are carried out. The regulations should be adaptable to be able to respond to new data as it is gathered on the health impacts of ENDS.

We have made remarkable progress in terms of tobacco control, but the increasing popularity of E-cigarettes threatens to undermine years of hard work. There is urgent need therefore to act now, to protect public health.

The author is the Regional Director of World Health Organization, South-East Asia Region.