BACKGROUND: For some people, electronic nicotine delivery systems (ENDS) may serve as a cessation support for cigarette use. For others, ENDS may be a gateway to cigarette use. Very little research has characterised the relationship between cigarette and ENDS use in South Africa. This paper aims to fill this gap.
METHODS: We analysed a nationally representative survey of urban South African adults. The survey included detailed questions regarding the respondents’ initiation and (where relevant) cessation dates for both cigarettes and ENDS.
We developed a typology describing the sequence in which dual users (ever-users of both cigarettes and ENDS) used each product. “On-rampers” are those users who used ENDS first and later took up cigarette smoking, and “off-rampers” are those users who first smoked cigarettes and who subsequently quit cigarettes while still using ENDS. Other groups were “non-off-rampers”, i.e., people who started using ENDS while smoking cigarettes, but later quit using ENDS, and “continuing dual users” who were still using both products at the time of the interview.
RESULTS: Based on the weighted data, 9.5% of dual users displayed “on-ramping” behaviour, 13.1% displayed “off-ramping” behaviour, 20.9% were “non-off-rampers” and 56.4% were “continuing dual users”. Roughly half of off-rampers, failed off-rampers and continuing dual users stated that they started using ENDS to help them quit cigarettes. 1.7% of the population were or had been ENDS users, but had no history of using cigarettes.
CONCLUSIONS: Policy interventions should attempt to minimize the on-ramp effect, and maximize the off-ramp effect. Specifically, ENDS use should be strongly discouraged amongst those who do not smoke cigarettes, especially young people. Targeted cessation support could be used to assist the “non-off-ramper” and “continuing dual user” groups, to successfully quit cigarettes. Additional research should investigate the nature of use (for example, the intensity of use), within each category.