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Stanford University School of Medicine

E-cigarettes a growing cause for concern in the developing world

It is a common misconception that e-cigarettes are a problem only in wealthy nations, say two Stanford global health researchers in a commentary published today in the Journal of the American Medical Association. In the piece, co-authors Michele Barry, MD, FACP and Andrew Chang, MD, call attention to the widespread availability of e-cigarettes in the developing world and a growing concern over the potential health implications unique to low- and middle-income countries.

Chang, an internal medicine resident in Stanford’s Global Health track planning to specialize in cardiology, has been closely tracking the conversation around global tobacco control, but noticed e-cigarettes have been largely absent from the discussion. With support from Barry, director of the Center for Innovation in Global Health, Chang dug deeper and found that while U.S. health officials and researchers have been grappling with uncertainties around e-cigarette regulation and health impacts, the rise of e-cigarettes has in fact become a global threat.

The authors point to a 2014 survey from the World Health Organization suggesting that already, more than half of the world’s population is living in countries where e-cigarettes – or electronic nicotine delivery systems (ENDS) – are available. Public awareness in many of these countries is high and the devices are cheap.

But in some parts of the world, notably Africa and South Asia, there is little to no data on e-cigarette awareness and usage trends. This is of particular concern, say Barry and Chang, as regions like Africa and South Asia represent vast potential markets and are likely to be hit hardest by the growth of e-cigarettes.

For one, low- and middle-income countries are more vulnerable to threats posed by big tobacco companies who have a track record of hidden lobbying to promote and enable “black market” tobacco among poor populations. The authors describe a potential scenario in which tobacco companies could use inexpensive e-cigarettes to entice new smokers and raise prices later, forcing users to switch to conventional cigarettes.

“What we are most concerned about is the entry of big tobacco on a global scale in which they could hijack the harm-reduction potential and recruit new and never users into smoking,” Chang said in a press release.

Even without the heavy hand of big tobacco companies, this scenario is already starting to play out in the U.S. Another study published today in JAMA found that high school students in Los Angeles who had used e-cigarettes were more likely to report using smokable tobacco – such as cigarettes, cigars or hookah – over the following year, compared to nonusers.

Perhaps even more alarming is the increased potential health effects of e-cigarettes that can stress low- and middle-income health systems relatively more than health systems in high-income countries, the authors wrote.

E-cigarette supporters tout the products as a safe alternative to smoking, but emerging data demonstrates that in the process of aerosolizing nicotine, e-cigarettes may produce known carcinogens such as formaldehyde and acetone and could increase the risk of cardiovascular disease – a leading cause of death in the developing world.

The authors point out that noncommunicable diseases, including heart disease and stroke, tend to strike people at a younger age in low- and middle-income countries due to fewer preventive strategies and lesser focus on primary care. This causes greater economic duress to families as more people are dying at their time of peak productivity.

Furthermore, crowded cities and uncontrolled population growth amplifies the potential for secondhand vapor exposure, and limited access to emergency medical care could magnify problems associated with the unintentional ingestion of e-cigarette fluids.

As countries around the world continue to wrestle with legal control of e-cigarettes, Chang and Barry urge low- and middle-income countries not to underestimate the availability and targeted marketing of e-cigarettes within their borders and to place e-cigarettes under the purview of their medical and pharmaceutical regulatory boards.

They conclude: “Even though e-cigarettes may have a future as smoking cessation tools, evidence to support this indication is lacking. More rigorous studies must be conducted regarding the awareness, usage patterns and potential for harm of these devices in low-income countries, particularly Africa and South Asia, where data are currently missing.”

Rachel Leslie is the communications officer at Stanford’s Center for Innovation in Global Health, which supported this research.

Previously: Teens confused about harms of marijuana and e-cigarettes, Stanford study finds, With e-cigarettes, tobacco isn’t the only danger, Stanford experts skeptical about motives behind e-cigarette health warnings, How e-cigarettes are sparking a new wave of tobacco marketing and E-cigarettes and the FDA: A conversation with a tobacco-marketing researcher
Photo by Joseph Morris

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