More than a quarter of matric pupils at wealthy South African high schools are vaping, and almost a quarter of those who use the devices say they cannot get through the school day without a hit, according to the preliminary findings of a pilot study.
The research sheds light on the explosion of e-cigarette use among teens in parts of SA and comes as Parliament is poised to consider tough new anti-tobacco laws that will, for the first time, regulate e-cigarettes.
This comes as Californians, in efforts to reduce vaping use among youngsters, this week overwhelmingly voted to ban all flavoured tobacco products in the state, making it the the largest state to ban such products – already illegal in places like Rhode Island, New Jersey, and Massachusetts.
US regulators have targeted flavoured products in particular because they are overwhelmingly preferred by young people. More than 84% of young people who vape reported using flavoured products, according to the Centres for Disease Control and Prevention (CDC).
In SA, the problem was "significant", said the study’s principal investigator, Richard van Zyl-Smit, deputy head of pulmonology at the University of Cape Town.
BusinessLIVE reports that the pilot study findings, which have not been published in a peer-review journal, were made public to make MPs aware of the situation, he said.
“These data need to get to parliamentarians. We have to get vaping regulated to reduce access to adolescents,” he said during a webinar hosted by the Health Department.
The study included 5 583 pupils from grades eight to 12 at nine quintile-five public and private schools in Gauteng, Western Cape and KwaZulu-Natal, who completed an online survey. Quintile-five schools are in well-off communities.
It found the prevalence of teenagers who had vaped in the past 30 days rose from 6.2% in grade 8 to 26.5% in grade 12. In the worst-affected school, 32.3% of matric pupils had vaped in the past month.
Overall the survey found 15.3% of the teenagers reported using e-cigarettes in the previous 30 days, 4% used inhaled tobacco products and 6.3% used cannabis.
The mean age at which teenagers started vaping was 14.7 years, compared with 14.2 years for tobacco products.
The prevalence of teen vaping identified in the high schools that participated in the pilot study stands in sharp contrast to the findings of the 2021 GATS-SA survey conducted by the Medical Research Council.
It found just 2.2% of people aged 15 or older used e-cigarettes, and that e-cigarette use was highest among people aged between 15 and 24, at 3.1%.
Van Zyl-Smit emphasised that the pilot study was not nationally representative and e-cigarette use is expected to vary widely between communities. “It may be less of an issue in poorer schools, (but) it is still an issue in these high schools.”
A larger follow-up study is in the pipeline, which will include between 150 and 200 schools.
The pilot study suggests a worryingly high level of nicotine-addiction among the teenagers who vaped, he said, with 30% of them saying they reached for a puff within five minutes of waking up.
Tried to quit
Almost two-thirds of e-cigarette users reported using their device in the first hour of the day. A total of 23% of vapers said they could not go through the school day without using their devices and 29.5% reported feeling anxious or angry if they could not vape. More than half (54%) said they had tried to quit. A stark finding of the research was that almost half (48.4%) of the teenagers who vaped said their parents knew about their habit.
The Control of Tobacco Products and Electronic Delivery Systems Bill was tabled in Parliament in September, proposing greater restrictions on smoking in public places, the introduction of plain packaging and picture warnings, the banning of vending machine sales, prohibition of point of sale advertising, and for the first time, the regulation of e-cigarettes and other new-generation products.
A British American Tobacco SA spokesperson said no one under 18 should have access to tobacco or nicotine products, and the company supports regulation to prevent this happening.
Meanwhile, California’s ban would also outlaw menthol cigarettes, which federal regulators have proposed banning nationwide because they argue such products are easier to start and harder to quit. Survey data also show that menthol cigarettes are overwhelmingly preferred by black smokers.
Tuesday’s vote is the latest twist in a more than two-year fight between California legislators and the tobacco industry. Lawmakers first passed the state’s flavour ban in 2020, but the tobacco industry quickly launched a multimillion dollar campaign to put the initiative to a popular vote.
The fate of the California ban, however, could ultimately be determined by a legal fight over a previously enacted ban in Los Angeles County. The tobacco company RJ Reynolds is currently challenging that initiative, on the grounds that federal tobacco law doesn’t allow states and localities to prohibit the sales of tobacco products. A federal appeals court ruled in March that states and municipalities do have the power to ban flavoured products, but the company asked the Supreme Court to review that decision in October.
If the Supreme Court agrees to take that case and sides with RJ Reynolds, it could torpedo California’s ban, as well as bans on the books in other states and localities, says Desmond Jenson, the lead senior staff attorney for federal regulation at the Public Health Law Center.
“There’s very good reason to be concerned about a Supreme Court decision,” Jenson said. “No court at any level has ever struck down a policy prohibiting the sale of flavoured tobacco products on federal preemption grounds, but that doesn’t mean the Supreme Court couldn’t decide otherwise and that ruling would apply everywhere.”
Pro-vaping advocates are likely to criticise California’s new ban as depriving adult tobacco users of flavoured vaping products, which are seen as less harmful than combustible cigarettes. There is not reliable data available on how many adults currently use flavoured vaping products, though the CDC estimates that 3.7% of adults nationwide vape.
Tobacco control advocates argue flavour bans will ultimately keep people – particularly youngsters – from getting hooked on nicotine, and they plan to use California’s newly enacted policy to increase pressure on other states to enact similar bans.
In Britain, health campaigners and experts are calling for graphic images and warnings on vaping products amid fears that the UK is sleepwalking into a public health disaster, saying the devices should be sold under the same rules as normal cigarettes.
The gadgets, popular among children, are judged to be much safer than smoking by some, but the long-term effects of e-cigarettes remain a mystery, and doctors fear a wave of lung disease and even cancer in the coming decades.
Experts told MailOnline the products should be sold under the same rules as regular cigarettes to dissuade young people from picking up the habit.
Professor Stephen Turner, a respiratory paediatrician at Royal Aberdeen Children’s Hospital, said: “Children should not use any nicotine-containing products, and e-cigarettes should be sold under the conditions currently applied to other over-the-counter nicotine-containing products.”
Cigarettes in the UK are currently sold with graphic warnings and in plain packaging.
Professor Andrew Bush, a paediatric respirologist at Imperial College London, said: “These things have not been around long enough for us to be complacent about them. They are being aggressively marketed to teenagers and younger children, and this must stop.”
Calls for tougher action come amid soaring vaping rates among British children. Despite it being illegal to sell e-cigarettes to under-18s, one in 10 secondary school pupils are now regular users – double the proportion less than a decade ago.
Almost every high street now has a designated vape shop, with e-cigarettes sold for as little as £5. They are often sold in glossy displays and in a variety of eye-catching colours and child-friendly names and flavours, like bubblegum and strawberry milkshake.
The marketing of the devices has been linked to alcopops, alcoholic drinks sold in bright neon-colours which are ultra sweet or fruit-flavoured.
A government-commissioned review published in June recommended a review of vape flavours to ensure they don't appeal to young people.
The paper, by former children's charity chief Javed Khan, also recommended that cartoons and images on vaping products be banned. It did not call for cigarette-style warnings, although it did admit warning labels about e-cigarettes’ harm do increase people’s perception of the risks.
The researchers said more studies are needed about the effectiveness of warning labels “highlighting the relative harms of smoking and vaping”.
Graphic warnings have been a mainstay of tobacco products in the UK since 2008, when smoking was first banned in pubs and restaurants. They were made bigger in 2016, and manufacturers were forced to put the messages on the front and back of packets.
They include both text and picture health warnings, such as an image of cancerous lungs. Vapes are currently only required to be sold with labels warning that they contain nicotine, which is highly addictive.
But these are often much smaller than those seen with cigarettes due to the packaging size and do not warn of other potential health risks.
E-cigarettes allow people to inhale nicotine in a vapour – produced by heating a liquid, which typically contains propylene glycol, glycerine, flavourings, and other chemicals. They can include hundreds of unregulated chemicals, some of which are “known carcinogens”, according to a study published in Frontiers in Paediatrics last October.
Bush said: “They are not regulated and they are not tested, and if anyone can find a website listing what’s in all these liquids and safe toxicity data, I’m his holiness the Pope. We cannot be confident, which is why I cannot say they are safe.”
Experts also fear the high nicotine content might increase blood pressure and cause other heart problems.
Several papers, including the government-commissioned report, suggest vaping has fewer cardiovascular risks than smoking and people making the switch have better heart function.
Hazel Cheeseman, deputy chief executive of Action on Smoking and Health, told MailOnline: “There are far too many scare stories about vaping and not enough rational discussion of the evidence.
“If you are a smoker, switching to vaping is much less risky than continuing to smoke. The information in these studies does not change this fact.
“Smokers should not be put off from using something that might literally save their lives.”
Health officials believe e-cigarettes can play a key role in weaning the remaining 5m smokers in Britain off tobacco and putting an end to the killer habit.
The government has set an ambition to become the smoke-free by 2030, and sees e-cigarettes as a vital tool to helping people quit.
What do recent studies on e-cigarettes say?
People who vape experience “worrisome changes” in their blood pressure. Vaping also causes your blood pressure and heart rate to spike immediately afterwards, a study claimed.
University of Wisconsin experts found vaping and smoking cause people's heart rates to spike 15 minutes after use and put the body in “fight or flight” mode.
The study looked at data for 395 participants – 164 vapers, 117 smokers and 114 who had no history of nicotine, e-cigarette or tobacco use.
Co-lead author Matthew Tattersall, an assistant professor of medicine at the university, said: “Immediately after vaping or smoking, there were worrisome changes in blood pressure, heart rate, heart rate variability and blood vessel tone (constriction).”
But the study has not been peer-reviewed and was only observational, so researchers could not prove vapes were actually causing the heart issues.
E-cigarette users are less fit than people who do not vape
Vapers perform worse when exercising than non-smokers and are more akin to smokers, a study claims.
Researchers looked at data from the same participants as the previous study.
After 90 minutes on the machine, they were given four heart screenings to determine overall health of the organ.
People who vaped scored 11% lower than those who did not use nicotine. Smokers had test scores 16% lower than the control group.
Dr Aruni Bhatnagar, a professor of medicine at the University of Louisville said: “These studies add to the growing body of science that shows similar cardiovascular injury among people who use e-cigarettes and those who smoke combustible cigarettes.”
Vaping is “just as bad as cigarettes for your heart”
Vapers are at the same risk of heart disease as cigarette users, according to US federally-funded research. In two studies, one on mice and one on people, e-cigarettes were found to cause similar damage to blood vessels as smoking tobacco.
The findings from experts at the University of California, San Francisco were published in the American Heart Association’s journal Arteriosclerosis, Thrombosis and Vascular Biology (ATVB).
Despite the difference in ingredients that make up e-cigarette aerosol and cigarette smoke, the researchers found that blood vessel damage does not appear to be caused by a specific component of cigarette smoke or e cigarette vapour.
Rather, it appears to be caused by airway irritation which triggers biological signals in the valgus nerve.
Dr Matthew Springer, a professor of medicine in the division of cardiology at the University of California, San Francisco said: “We were surprised to find that there was not a single component that you could remove to stop the damaging effect of smoke or vapours on the blood vessels.”'
“As long as there’s an irritant in the airway, blood vessel function may be impaired,” he said.
Study 1 details
E-Cigarettes as a Growing Threat for Children and Adolescents: Position Statement From the European Academy of Paediatrics
Andrew Bush, Agnieszka Lintowska, Artur Mazur, Adamos Hadjipanayis, Zacchi Grossman, Stefano Del Torso, Pierre-André Michaud, Svitlana Doan, Ivanna Romankevych, Monique Slaats, Algirdas Utkus, Łukasz Dembiński, Marija Slobodanac, Arunas Valiulis.
Published in Frontiers in Paediatrics 4 October 2021
Abstract
As the tobacco epidemic has waned, it has been followed by the advent of electronic nicotine delivery devices (ENDS) primarily manufactured by the tobacco industry to try to recruit replacements for deceased tobacco addicts. This document sets out the ten recommendations of the European Academy of Paediatrics (EAP) with regard to e-cigarettes and children and young people (CYP). The EAP notes that nicotine is itself a drug of addiction, with toxicity to the foetus, child and adult, and were ENDS only to contain nicotine, their use to create a new generation of addicts would be rigorously opposed. However, e-cigarettes include numerous unregulated chemicals, including known carcinogens, whose acute and long term toxicities are unknown. The EAP asserts that there is incontrovertible evidence that the acute toxicity of e-cigarettes is greater than that of "traditional" tobacco smoking, and a variety of acute pulmonary toxicities, including acute lung injuries, have been recorded due to e-cigarettes usage. The chronic toxicity of e-cigarettes is unknown, but given the greater acute toxicity compared to tobacco, the EAP cannot assume that e-cigarettes are safer in the long term. The high uptake of e-cigarettes by CYP, including under-age children, is partly fuelled by deceitful marketing and internet exposure, which is also unregulated. Although proposed as aids to smoking cessation, there is no evidence that e-cigarettes add anything to standard smoking cessation strategies. In summary, the EAP regards these devices and liquids as very dangerous, and ineluctably opposed to their use, and their direct or indirect marketing.
Study 2 details
Impairment of Endothelial Function by Cigarette Smoke Is Not Caused by a Specific Smoke Constituent, but by Vagal Input From the Airway
Pooneh Nabavizadeh, Jiangtao Liu, Poonam Rao,Sharina Ibrahim, Daniel D. Han,
Ronak Derakhshandeh, Huiliang Qiu, Xiaoyin Wang, Matthew Springer et al.
Published in Arteriosclerosis, Thrombosis, and Vascular Biology (ATVB) on 26 October. 2022
Abstract
Background
Exposure to tobacco or marijuana smoke, or e-cigarette aerosols, causes vascular endothelial dysfunction in humans and rats. We aimed to determine what constituent, or class of constituents, of smoke is responsible for endothelial functional impairment.
Methods
We investigated several smoke constituents that we hypothesised to mediate this effect by exposing rats and measuring arterial flow-mediated dilation (FMD) pre- and post-exposure. We measured FMD before and after inhalation of sidestream smoke from research cigarettes containing normal and reduced nicotine level with and without menthol, as well as 2 of the main aldehyde gases found in both smoke and e-cigarette aerosol (acrolein and acetaldehyde), and inert carbon nanoparticles.
Results
FMD was reduced by all 4 kinds of research cigarettes, with extent of reduction ranging from 20% to 46% depending on the cigarette type. While nicotine was not required for the impairment, higher nicotine levels in smoke were associated with a greater percent reduction of FMD (41.1±4.5% reduction versus 19.2±9.5%; P=0.047). Lower menthol levels were also associated with a greater percent reduction of FMD (18.5±9.8% versus 40.5±4.8%; P=0.048). Inhalation of acrolein or acetaldehyde gases at smoke-relevant concentrations impaired FMD by roughly 50% (P=0.001). However, inhalation of inert carbon nanoparticles at smoke-relevant concentrations with no gas phase also impaired FMD by a comparable amount (P<0.001). Bilateral cervical vagotomy blocked the impairment of FMD by tobacco smoke.
Conclusions
There is no single constituent or class of constituents responsible for acute impairment of endothelial function by smoke; rather, we propose that acute endothelial dysfunction by disparate inhaled products is caused by vagus nerve signaling initiated by airway irritation.
BusinessLIVE article – Teen vaping explodes in wealthy high schools, pilot study finds (Open access)
Vaping industry exploits SA’s policy gap, enticing more to young people to smoke
UK report on vaping flavours (Open access)
STAT News article ¬– California bans flavored tobacco products, including vapes (Open access)
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Vaping could save 104,000 Australian lives – modelling study
Researchers expose the ‘pitiful quality’ of highly cited vaping studies
Anti-vaping bias undermines e-cigarette research? Study raises questions
Vaping – Time for doctors to get on board
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