Electronic nicotine delivery systems in Brazil: to ban or not to ban, that’s the question

Introduction: Debates on policy options for tobacco “endgame” have suggested that addicted cigarette smokers have access to likely less toxic alternative sources of nicotine. Methods: We discussed facts and challenges pertaining to current regulatory environment on electronic nicotine delivery systems (ENDS) in Brazil, including conventional cigarette smoking prevalence, burden of mortality, morbidity and costs for society associated with smoking, and the current tobacco control policy. Results: In Brazil, advertising/sale of ENDS has been banned since 2009. However, in 2019, under strong pressure from the tobacco industry, the National Sanitary Surveillance Agency decided to include in its regulatory agenda the discussion about the current ENDS restriction. Brazil has achieved the largest decrease in daily smoking prevalence in the world between 1990 and 2015; however, there are still 20 million conventional cigarette smokers and 162 thousand tobacco-related deaths per year, and the annual cost of smoking is US$22 billion. This scenario stimulates a debate about the risks and benefits of changing current ENDS regulation to allow adult smokers to have legal access to non-combusted sources of nicotine, such as ENDS. One of the main concerns is that young people might become more vulnerable to smoking uptake after a massive introduction of ENDS. Conclusions: Understanding how the emerging ENDS market may adversely or positively affect tobacco control outcomes is crucial for developing public health policies. Although this paper focused primarily on the Brazilian context, the issues raised by the authors may be useful for other countries facing the same dilemma.