Mixed Messages On Smoking And Vape

Big tobacco is transitioning from cigarettes to vape, e-cigarettes and heat-not-burn devices.

The intention to tax vapes and e-cigarettes as announced by the Finance Minister during the tabling of Budget 2022, and the revelation by the Health Minister that the government would be tabling a Tobacco and Smoking Control Bill regulating all tobacco-related products including electronic cigarettes and vaping devices, are both seen with welcome relief and alarm.

Such legislation will certainly help ensure consistency and harmonisation of the government’s policy positions and decisions about tobacco control and its management. It will also be expected to be updated to clear up confusion or misunderstanding regarding tobacco devices which don’t fit current legal definitions.

It is important that the government stands firm on any decision to review, regulate and plug loopholes or shortcomings in the existing tobacco control regulations.

However, what is worrying is the government planning to regularise and tax vape liquids containing nicotine. Regulating instead of banning vape and e-cigarettes outright, which countries like Singapore, Brunei, and Thailand have done. This is a move that has been applauded by not only the vape and e-cigarette industry, but also the large tobacco firms. There is a reason for this.

Big tobacco is transitioning from traditional tobacco combustible products such as cigarettes to vape, e-cigarettes and heat-not-burn (HNB) devices. Both the tobacco industry and its counterparts in the vape sector are aggressively promoting e-cigarettes as a supposed reduced-risk alternative for smokers.

The local vape industry is estimated to be worth almost RM 3 billion. According to the National Health and Morbidity Survey 2019, there is an estimated 1.12 million vapers in Malaysia. They are also getting younger.

The tobacco industry has had a well-documented history of targeting young people for its products, especially in large developing markets such as China and Indonesia. We should expect the same strategy from the vape industry.

In these countries, rather than following the global trend of decreasing numbers of new smokers and more people quitting, the prevalence of young smokers has been on the increase.

Almost 70 percent of Indonesian males smoke, one of the highest adult male smoking rates in the world, including 41 percent of youths between 13 and 15 years. 20 percent of adolescents have first tried cigarettes before the age 10. The industry is now targeting young Indonesian women.

There are an estimated 4.7 million male smokers in Malaysia, and more than 135,000 smokers among women. 35 men smoke for every female smoker. That represents 49 percent of men aged 30 to 34. Smoking prevalence is 45 percent or higher across all age groups among men. For male teens aged 15 to 19, almost 25 percent smoke.

To quote a Philip Morris memo from 1981, “today’s teenager is tomorrow’s potential regular customer.”

Targeting young people is a time-proven business strategy, especially when dealing with nicotine.

Just as it was for cigarettes, fundamental to the success of vape and e-cigarettes are new or existing young users.

E-cigarettes range from heat-not-burn (HNB) cigarettes to heating a liquid containing nicotine, propylene glycol, glycerine and flavouring resulting in a vapour or aerosol (vaping).

Findings from the Tobacco and E-cigarette Survey among Malaysian Adolescents 2016 (Tecma) raised the concern for many public health professionals: 36.9 percent of students start using e-cigarettes between the ages of 14 and 15; more young women are experimenting with e-cigarettes for the first time as compared to conventional cigarettes which are viewed negatively.

Because of their form factor which is often sleek and sophisticated, looking like cool USB drives or glowing pens, coupled together with messaging which claims that smoking e-cigarettes are healthier than smoking tobacco, these devices are a serious problem. They appear to be deliberately designed to attract and appeal to young users, with flavours such as teh tarik, air bandung, and packaging materials that are bright and colourful.

A media report found that Standard 6 students in Seberang Perai were using devices smoking supposedly fruit flavoured vape juice such as watermelon. With disposable vape pens containing between 1- 5% nicotine available for RM 20 and open delivery systems, e-cigarettes will rapidly become a major contributor to the problem of nicotine addiction among young people in Malaysia.

An expert scientific panel convened by the US Food & Drug Administration and a South Korean study have respectively provided evidence of health risks and contradicted the claim that conventional cigarette smokers will switch to heated tobacco products.

The US FDA found that when smokers switched from traditional cigarettes to “heat-not-burn” devices, there were no evidence of improvements in lung function or reductions in tobacco-related blood vessel damage and inflammation. The available evidence suggests that the devices are just as harmful to the lungs and immune system as traditional cigarettes.

In the South Korea study, current e-cigarette users were more likely to also smoke conventional cigarettes and/or e-cigarettes. This contradicted the tobacco industry’s claims that smokers would switch from conventional cigarette to heated tobacco products.

A common concern is the possibility of a “gateway” effect where EC users eventually end up developing a nicotine addiction. Vapers will find that though they may have stopped smoking cigarettes, their nicotine addiction has transferred to e-cigarettes and vape. They either continued vaping, take up cigarettes or smoked both vapes and cigarettes, becoming dual users. A study among 1300 university students from 6 universities in Malaysia found that 75% smoked e-cigarettes or vape, but that 40% did both.

The long-term health effects due to the heating of these chemicals and the toxins produced are still unknown. Existing risk studies also appear to be limited to closed EC systems, but very few if any, on open systems which have the potential to inflict real harm due to unregulated nicotine usage.

Today, smoking cessation clinics, including those in Malaysia, are treating patients who are trying to quit smoking cigarettes, vape or both. Users of EC and vape find themselves wanting to quit.

Quitting is hard. There are no shortcuts. It has been estimated that it takes smokers at least 30 attempts, and relapse rates are high.

We need to increase access and easy availability of nicotine replacement therapy (NRTs) products such as nicotine patches and gum, which have been shown to be successful in helping smokers to quit smoking and be free of their nicotine addiction. These need to be reclassified to allow for over-the-counter sales which would enable for them to be available at the checkout counters of places such as convenience stores. They are currently only available from a pharmacist and should be made a lot easier for people to purchase.

It will take twelve weeks, and as long as six months, but those on NRT to treat their addiction will find that they can achieve full cessation of both tobacco and nicotine. Declassification of NRTs will improve their access and use by people wanting to quit smoking and vaping through a smoke-free approach.

It is important for the government to support smokers wanting to be cured of their nicotine addiction using proven and evidence-based approaches such as NRTs.

Azrul Mohd Khalib is Chief Executive Officer of the Galen Centre for Health & Social Policy

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