Reassessing Spinola et al.: data, sources, and the case for Brazil's e-cigarette ban

Spinola et al.¹ argued that because Brazil prohibits the import, manufacture and sale of e-cigarettes there has been a rapid increase in adult e-cigarette use (by 600% from 2018 to 2023) resulting in more dangerous products being available than in countries that allow them. Like the tobacco industry and e-cigarette advocates,2, 3, 4, 5, 6 they argue to repeal the ban and create a regulated market.

The increase Spinola et al. cite is from a survey conducted for the tobacco industry that consistently overestimates the size of the illicit market.⁷ Spinola et al. ignore Ministry of Health surveys that report adult e-cigarette prevalence has been essentially constant around 2.3% from 2019–2023.⁸ Had the authors used Ministry of Health statistics, their argument would have evaporated.

Spinola et al. overstate e-cigarette use in Brazil. They state “nearly one-quarter of Brazilian adolescents have experimented with e-cigarettes;” but the cited source⁹ shows only 18.1% of 13–18 year olds ever used e-cigarettes, far below “one quarter.” Past 30-day use—which Spinola et al. ignored—was 3.4%. They do not compare Brazil with countries that have legalized e-cigarettes. In the US, which has followed their recommended policy, 27.5% of high school students (age 14–18) had ever used e-cigarettes and 5.8% were current users.¹⁰

“Among adults, around 3.1 million exclusively use e-cigarettes, while approximately 8 million use both e-cigarettes and another tobacco product” is also an overstatement. The authors cite Menezes et al.,¹¹ which reports ever but not current use. Furthermore, adding the number of people using different products Menezes et al. report yields 6.7 million, not 8 million, adults.

Spinola et al. reference several papers to support statements in their manuscript; however, these cited sources do not actually substantiate the claims (Table 1).

Table 1.

Spinola et al. statements not supported by cited sources.

Spinola et al. statement	Comment
“This widespread use and availability of e-cigarettes is the result of a thriving illicit market that circumvents regulatory controls, flooding the market with unauthorized—and potentially even more hazardous—e-cigarettes than those found in regulated environments.”	The paper Spinola et al. cite12 to support this statement is a marketing research study estimating how price changes combined with a nicotine standard would be expected to affect purchasing decisions. This paper does not contain any data on the toxicity of authorized e-cigarettes compared to illicit e-cigarettes.
“Many are ‘knock-off’ devices that imitate well-known brands but lack basic safety standards, traceable origins, or health warnings. A government-backed investigation uncovered 1822 illicit social media advertisements or accounts related to e-cigarettes, underscoring the easy online access to banned products.”	Nothing in the Ministry of Justice and Public Security report13 the authors cite supports this statement. While the statement, “A government-backed investigation uncovered 1822 illicit social media advertisements or accounts related to e-cigarettes, underscoring the easy online access to banned products” is accurate, the implication in the paper is that the government is not doing anything about it. The report documents the opposite conclusion.
“A recent study found disposable vapes in Brazil contained metal concentrations far above acceptable levels for inhaled materials.”	The authors cite a news story14 to support this statement. The actual published study15 concludes, “Significant toxicity was observed in products from both countries where sale is prohibited and countries where it is regulated.”

Spinola et al.’s statement that “It is crucial that Brazil adopts measures to mitigate the risks associated with e-cigarettes,” while true, ignores the Ministry of Health's monitoring of e-cigarette use (discussed above) and implementing other policies, including aggressive policing of e-cigarette sales on the internet.¹⁶ Indeed, the authors recognize that “Brazil has made progress in confiscating illegal e-cigarettes; … confiscating nearly 2 million units valued at approximately R$1.1 billion, a 57% increase compared to 2023.” We agree that “continued efforts are needed to restrict the supply chain flow of illegal products across its borders.”

Significantly, the authors do not present data from a single country where the permissive policy they urge has led to lower e-cigarette use among youth or adults or been associated with fewer adverse health effects compared to Brazil or other countries with bans. Quite the contrary, they recognize that “challenges with illicit supply remain even in regulated markets such as seen in the USA.” This statement is inconsistent with the authors’ thesis that legalization leads to better outcomes.

Spinola et al. should replace their paper with a version that corrects all these serious errors to prevent the tobacco industry and its allies from ignoring the criticisms and continuing to cite the paper^17,18 in lobbying efforts¹⁹ to overturn e-cigarette bans in Brazil and other countries.

Contributors

Both authors contributed to the writing of the final manuscript.

Declaration of interests

None reported.