Experts: E-Cigarettes Not ‘Decisively Proven’ As Nicotine Gum, Patches To Quit Smoking

Health experts say “it’s a matter of time” when researchers will be able to associate more diseases, including lung cancer, with e-cigarettes as was done with conventional cigarettes.

KUALA LUMPUR, March 3 – The role of vapes or e-cigarettes, which was first introduced in the early 2000s, for smoking cessation remains debatable, compared to more established nicotine replacement therapy (NRT) products such as nicotine patches and gum.

Researchers from the Cochrane Review on e-cigarettes for smoking cessation, published in September last year, even said that they were only “moderately confident” that nicotine e-cigarettes can help more people stop smoking compared to NRTs, suggesting that more studies were “still needed” to confirm this.

They also said it was “uncertain” if the unwanted effects that occur when using nicotine e-cigarettes were comparable to those with NRTs, noting that the unwanted effects with nicotine e‐cigarettes were throat or mouth irritation, headache, cough, and feeling sick.

Unlike regular cigarettes that combust and burn tobacco, e-cigarettes heat a liquid that usually contains nicotine, flavourings, and other chemicals that help make the aerosol. According to the US’ Centers for Disease Control and Prevention (CDC), the e-cigarette aerosol that is breathed in and exhaled can contain harmful substances like cancer-causing chemicals and heavy metals like nickel, tin, and lead.

Galen Centre for Health and Social Policy chief executive Azrul Mohd Khalib said it has never been “decisively proven” through studies that vapes or e-cigarettes are an effective smoking cessation tool in comparison with NRTs, as Malaysia moves to regulate e-cigarettes.

“It’s never been really decisively proven through studies that vape or e-cigarettes is an effective smoking cessation tool in comparison to NRT products where you have gum, you have patches, and in some countries, sprays, where you can basically have, since the 70s, data that demonstrates over 300 clinical studies, 40 years of real-world experience showcasing the safety and efficacy of these approaches for smokers who want to quit.

“And right now, what we are looking at is, somehow, giving up on these existing approaches, or what we call NRT products and moving on to something that has not yet been proven, as a way to one, supposedly reduce harm and two, as a way to quit smoking, which is quite erroneous,” Azrul said in a BFM podcast on the country’s smoking cessation strategies.

Prof Dr Mohamad Haniki Nik Mohamed, who is chief coordinator of the Certified Smoking Cessation Service Provider (CSCSP) at the Kulliyyah of Pharmacy, International Islamic University Malaysia, also sounded caution on inadequate long-term data on e-cigarettes.

“I do not deny that we have data that e-cigarettes do help smokers quit. However, we still don’t have the long-term safety data [on e-cigarettes] because it is a relatively new phenomenon compared to data from studies on NRT. So, we don’t know the long-term harmful effects.

“But [there is] EVALI (e-cigarette or vaping use-associated lung injury) which erupted in 2019. EVALI [showed] it can result in death and permanent destruction to the respiratory system, particularly the lungs in those who use e-cigarettes.

“At the very least, we need to understand that whatever is put into e-cigarettes, whether it’s the nicotine, whether it’s the flavouring agents, or the humidifiers — like propylene glycol or vegetable glycerin — these are not meant to be inhaled. 

“Our lungs are meant to inhale fresh air containing oxygen and then expire or expel out gases like carbon dioxide, not to inhale, lychee or bandung syrup or watermelon flavoured, teh tarik, or what have you.

“You can drink and have food containing all these flavouring agents because they go through another system, the gastrointestinal tract but not meant for the respiratory tract. 

“These can be irritants, they can evoke processes of inflammation, they can start the process of carcinogenesis, they can, in the long term, even cause cancer, cardiovascular problems, on top of respiratory problems.

“It’s a matter of time when researchers will be able to associate more and more diseases with e-cigarettes as they have done with combustible or conventional cigarettes (tobacco) because it took more than 20 years, almost 30 years to have a definite association between smoking and lung cancer,” Dr Mohd Haniki said.

Bangi MP Ong Kian Ming told CodeBlue that emphasis should be on the use of NRT products in helping smokers quit, instead of promoting e-cigarettes or vapes as smoking cessation tools or as a tobacco harm reduction strategy.

“For the NRTs, I think they should be incorporated into any public health campaign for tobacco cessation and harm reduction. I’m unaware of any recent campaigns being run by the Ministry of Health (MOH) for tobacco cessation at this moment, understandable given the situation with Covid-19. 

“However, I take note that NRT is being listed as one of the ‘Drug Facts’ on the MyHealth website under the MOH. I also take note that NRT was one of the methods used in the Quit Smoking Clinics programme in Seremban in 2019, via this study, which shows that taking NRT was a positive and significant predictor of success in quitting smoking,” Ong said.

According to the CDC, 2,807 hospitalised EVALI cases or deaths have been reported in the US as of February 18, 2020.

The US national emergency department data and active case reporting from state health departments around the country showed a sharp rise in symptoms or cases of EVALI in August 2019, a peak in September 2019, and a gradual, but persistent decline since then.

The CDC attributed the decline to several factors including increased public awareness of the risk associated with tetrahydrocannabinol (THC)-containing e-cigarette or vape products, removal of vitamin E acetate from some products, and law enforcement actions related to illicit products.

THC is the psychoactive substance that produces the “high” associated with smoking marijuana and can also lead to central nervous system depression. Vitamin E acetate, a honey-like substance used as an additive or thickening agent in some vaping products, might impair people’s lung function as the organ may not be able to process the substance.

Both the CDC and the US Food and Drug Administration (FDA) recommend that people not use THC-containing e-cigarette, or vaping products, particularly from informal sources like friends, family, or in-person or online dealers.

US authorities also recommend that adults using nicotine-containing e-cigarette or vaping products as an alternative to cigarettes should not go back to smoking. Instead, they should weigh all available information and consider using FDA-approved smoking cessation medications such as NRT products.

Dr Mohd Haniki said current evidence from EVALI shows that we should not wait another 30 years before e-cigarettes are viewed as dangerous.

“So, let’s ban it, because by that time it will be too late. Once you have recognised the industry as legitimate, it’s very difficult to go back retrospectively and pull them out from the market as we have seen with the tobacco industry,” he said.

Azrul argued that regularising or normalising e-cigarettes would create another problem – namely, people using e-cigarettes at much younger ages.

A study on 1,302 students at six local universities published in December 2018 found that 74.8 per cent of students used e-cigarettes, of which 34.5 per cent were exclusive e-cigarette users and 40.3 per cent were dual users. The study also found that 20.4 per cent of students were e-cigarette users who never smoked.

“People are starting to vape and use e-cigarettes at much younger ages now, at even secondary school level. We are seeing how they’re adopting the habit which arguably is a possible gateway towards cigarette smoking. 

“So, we need to have a look at our policies concerning tobacco and see how realistic they are and most importantly, be, as mentioned by Dr Haniki, to have the political will to make some of the decisive policy decisions such as what’s been done in New Zealand,” Azrul said.

Health Minister Khairy Jamaluddin previously announced plans to ban the sale of cigarettes, tobacco, as well as vape and e-cigarettes to everyone born after 2005, similar to New Zealand’s recent move in banning the sale of tobacco to anyone born after 2008.

The wide-ranging prohibition will be included in a new Tobacco and Smoking Control Bill that Khairy intends to table in the ongoing Parliament meeting to replace current tobacco product control legislations under the Food Act 1983.

New Zealand’s proposal, starting in 2027, will progressively raise the legal smoking age from 18 every year, allowing existing smokers to continue to buy cigarettes but effectively making tobacco products unavailable to everyone born after 2008. However, New Zealand’s proposed legislation does not ban vaping.

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