Vaping’s double-edged sword

Where there’s scientific smoke, there’s fire. The research around vaping is no exception.

The World Health Organisation (WHO) is fuelling the fire by warning that e-cigarettes are behind an “alarming” new wave of nicotine addiction in children.

The WHO’s recently issued global estimate of e-cigarette use is a first.

It puts numbers around what parents, teachers and clinicians have long feared: among more than 100-million people who vape worldwide are about 15-million children aged 13-15.

In countries with usable data, adolescents are shown to be on average nine times more likely to vape than adults.

Given how rapidly vaping has caught on among South African school-going children and how many users appear addicted it’s no mere trend.

The WHO sees all the hallmarks of a “vaping epidemic” for adolescents.

‘Hooking kids on nicotine’

E-cigarettes are widely marketed as harm reduction. In reality, according to WHO director of health determinants, promotion and prevention Etienne Krug, they are “hooking kids on nicotine earlier and risk undermining decades of progress”.

That comment contains two uncomfortable truths. The first is pragmatic: for adults who smoke, increasingly strong evidence shows that nicotine-containing e-cigarettes can help them to stop smoking — at least in the short term.

A Cochrane Collaboration “living” review (a continuously updated analysis of the latest studies) finds strong evidence that nicotine e-cigarettes increase quit rates at six months compared with nicotine replacement therapies, such as gum or patches.

In randomised trials (the “gold standard” of modern medical science), more smokers quit with vapes than with traditional replacement products.

For a smoker who has tried everything else, that is not a nicety; it may be a lifeline.

The second truth is moral and epidemiological: e-cigarettes that may help some adults stop smoking conventional cigarettes are simultaneously and disproportionately seducing children who have never smoked.

That irony is at the heart of the WHO’s warning. In many countries, young vapers have never even puffed on a cigarette. The global tobacco industry is creating new nicotine addicts, not merely converting smokers to supposedly safer technology.

E-cigarettes that may help some adults stop smoking conventional cigarettes are simultaneously and disproportionately seducing children who have never smoked.

Fortunately for the industry, science resists one-sided moral reasoning. The clinical benefits of vaping for adult cessation appear clear.

Modelling studies suggest that if smokers switched completely to e-cigarettes (no dual use, no return to cigarettes), gains could be profound.

One highly cited study in the journal Tobacco Control in 2018 projected that replacing cigarette smoking with vaping over 10 years in the US alone could avert between 1.6-million and 6.6-million premature deaths while resulting in between 20.8-million and 86.7-million fewer lost life-years (the average number of years a person is expected to live).

That depended on assumptions about relative harm, switching rates and initiation. Even under the more pessimistic scenario, the predicted public health benefits remain substantial.

Another recent model, more conservative in its disease assumptions, found “substantial reductions in deaths and life-years lost” tied to complete substitution of smoking with vaping.

These forecasts are not prophecy and they rest on behavioural assumptions that may or may not hold. But they demand attention.

They remind us that the same devices ensnaring children could, under strict adult-only use, reduce smoking-related deaths on a scale once thought impossible

South Africa is not immune to this paradox. A groundbreaking study led by University of Cape Town (UCT) researchers and published in the Lancet E Clinical Medicine journal in December 2024 surveyed more than 25,000 pupils across 52 fee-paying schools. It uncovered startling levels of vaping among high school pupils, with nearly 30% of matric students reporting active use.

UCT pulmonologist Prof Richard van Zyl-Smit, an expert in tobacco and vaping research at Groote Schuur Hospital, said that the findings emphasise the highly addictive nature of vaping products.

“Nicotine use during adolescence can harm the developing brain, with potential long-term effects on learning, memory and attention,” he said. “Alarmingly, it also increases the risk of progression to conventional cigarette smoking.”

Nicotine use during adolescence can harm the developing brain, with potential long-term effects on learning, memory and attention.

—  Prof Richard van Zyl-Smit

The Cancer Association of South Africa and other public health voices describe patterns of experimentation, frequent use and a disturbing gap between vaping and traditional smoking prevalence.

A large umbrella review published in Tobacco Control in 2025 found that children who vape were more likely to take up smoking, report asthma and experience poor mental health.

Again, observation suggests only association, not causation. However, for policymakers, the possibility that vaping acts as a gateway or marker for other harms is more than a statistical curiosity; it is reason enough to act.

A confounding factor in the debate is the distinct risks that disposable vapes and pod systems present for children.

Cheap disposable vapes (single-use devices prefilled with high-strength nicotine salts and sold cheaply) are especially attractive: easy to hide, brightly packaged, sweet-flavoured and able to deliver rapid, smooth nicotine hits that accelerate addiction.

They may also contain toxic substances, chemical additives, flavouring compounds, colourants and metals that can harm developing lungs, albeit at generally lower levels than cigarettes.

Pod systems, by contrast, are less appealing for first-time use but pose acute toxicity risk when filled with illicit or adulterated liquids. These include THC (the active ingredient in cannabis) cartridges containing vitamin-E acetate, which is linked to severe lung injury.

Some countries, including the UK, Belgium, New Zealand, Bangladesh and Kyrgyzstan, have banned disposable vapes to curb youth access and environmental waste.

At the far end of the regulatory spectrum, Singapore, Thailand, India, Cambodia, Laos and Qatar prohibit the sale, import or use of all vaping products, often with harsh penalties.

Outright bans often drive products underground, expand black-market supply and may push adult smokers back to cigarettes. This makes full prohibition a blunt instrument that can worsen rather than reduce harm.

That reasoning drives a growing South African chorus calling for firm regulation. Editorials and commentaries urge parliament to move swiftly on the Tobacco Products and Electronic Delivery Systems Bill, treat vapes like tobacco products, ban youth-targeted advertising and flavours and close loopholes allowing online sales to bypass age checks.

Public health experts stress the importance of local context; smoking patterns, socioeconomic gradients and the size of the adult smoking population differ from those in high-income countries where harm-reduction arguments are most loudly made.

The calculus that justifies liberal vaping policies in some places does not translate automatically to South Africa.

Industry defenders continue to point to harm reduction and former smokers who claim e-cigarettes saved their lives. That anecdotal truth should solicit sympathy.

Yet public health response is not the comparison of anecdotes; it is measurement, prudence and distributional thinking. It raises questions of just how many lives are saved by adult switching and how many futures are altered by adolescent addiction?

The WHO argues that regulation should preserve cessation potential for adult smokers while erecting high walls to prevent youth uptake. Bricks in that wall should include advertising bans, flavour restrictions, taxation, plain packaging and robust age verification.

Messaging is an aggravating factor. Some public health specialists rightly fear repeating the slow catastrophe of tobacco denialism, overstating the risks of vaping and discouraging smokers from switching.

Others fear the opposite error: of sanitising vaping into a harmless lifestyle product that becomes normalised among children.

Public Health England’s widely cited figure of vaping as “95% safer” than tobacco smoking has become a rhetorical cudgel in these debates; it was a contested estimate and “safer” is not the same as “safe”, especially for developing brains.

South African researchers emphasise nuance: for clinicians helping adult smokers quit, e-cigarettes may be part of the toolkit; for children at school with disposable flavoured devices in their pockets, those devices are part of a public health emergency.

That leaves WHO’s alarm not as a call for moral panic but rather for balance underpinned by action. Stringent regulation and enforcement can protect children while preserving access to regulated cessation tools for adults who need them.

South Africa’s policy levers exist in a debate that is never purely scientific and is also social, economic and ethical.

If not, then the WHO’s warning risks sounding less like an alarm and, in time, more like an epitaph for child victims of vaping.

Business Day