KUALA LUMPUR, Sept 30 – The government’s plan to ban smoking and the sale of all tobacco products to the next generation should be carried out in phases instead of an outright ban, physicians at the Malaysia Society for Harm Reduction (MSHR) said.
According to the MSHR, the generational end game (GEG) – which aims to prohibit tobacco and vape for anyone born from January 1, 2007 – should not be incorporated into the Control of Tobacco Product and Smoking Bill 2022 until it is reviewed and revised to scientifically-backed harm reduction principles, such as allowing the use of e-cigarettes or vape as an alternative to smoked tobacco like cigarettes.
The group added that prohibitive approaches to fine and punish offenders of the tobacco control legislation should be eliminated.
“Rather than implementing a hard end game policy that has not been proven to work, even in the most regulated of tobacco markets, we stress on a need to deep dive into tobacco harm reduction (THR) scientific evidences to determine the best way forward in tobacco control while identifying gaps that can be addressed by activating local research activities,” MSHR said in their statement at a roundtable discussion here yesterday.
The harm reduction doctors’ group cited New Zealand’s phased approach to cut smoking prevalence in its Smokefree Aotearoa Action Plan, which began with tobacco regulations and education to reduce supply and demand, followed by the government’s explicit recognition of vape as a harm reduction product that offers an alternative to smoking.
Tobacco harm reduction is a public health strategy to lower the health risks to individuals and wider society associated with using tobacco products. This approach is widely practised in areas where an “abstinence-only” approach is ineffective, similar to syringe exchange programmes that offer less harmful options for drug users.
Like New Zealand, MSHR argued for the inclusion of vape as a method for harm reduction due to its “efficacy rates” over other harm reduction methods.
“The way we approach it is really tailored to how we can actually overcome their smoking problem. And I want to reinstate here that in the end, we want to gradually move into a total ban on vape, anti-vape. But some people will take a few years to quit, others take a few months, and only a small percentage take one or two days – even without nicotine replacement therapy.
“So, it is really here where we have to consider the difference. If some people cannot overcome their smoking habit with nicotine replacement therapy, that is when we have to look at other safer options – that is where you go for either e-cigarettes or vaping,” said Prof Dr Mohamad Hussain Habil, a psychiatrist at the Universiti Malaya Specialist Centre and advisor of MSHR.
Highlighting the importance and effectiveness of vape, Insaf Murni Association of Malaysia (IMAM) president Dr Mohd Khafidz Ishak cited data by the National Academy of Science, Engineering, and Medicine (NASEM) in the United States and the Public Health of England (PHE) in the United Kingdom on the efficacy of vape as a harm reduction tool.
“According to the NASEM in the US, e-cigarettes are likely to be far less harmful than combustible tobacco. The PHE also found e-cigarettes to be 95 per cent safer than smoking tobacco, and can help smokers quit. This is the alternative we can use for tobacco harm reduction,” said Dr Khafidz, who primarily deals with cases of drug abuse.
In a report published in August 2015, the PHE found that e-cigarettes are 95 per cent less harmful than normal cigarettes, and when paired with a smoking cessation service, helps most smokers to quit tobacco altogether. It should be noted, however, that the UK has strict laws for the sale of e-cigarettes and vapes.
In the UK, e-cigarette tanks are not allowed to have more than 20mg/ml of nicotine and vape liquids should not contain certain ingredients like caffeine, colourings, and taurine. The tanks must also include new labelling requirements and warnings.
MSHR president Prof Dr Sharifa Ezat Wan Puteh said that vape should be regulated in Malaysia in order to work as a harm reduction tool.
Dr Sharifa Ezat highlighted Australia’s approach of turning vape into a prescription drug to be used for tobacco harm reduction.
“This way, it causes a deterrence as not many can access vape in Australia. So if you look at the smoking prevalence between New Zealand and Australia, the smoking prevalence comes down faster in New Zealand because they don’t have this provision,” she said.
“But of course, allowing vape can cause other things. It can cause adolescents to be hooked earlier to vape because of the nicotine. Another way of looking at what happens in New Zealand is you can say, ‘Okay, at least they are not hooked on cigarettes.’
“But for New Zealand, they consider vape as something far safer than cigarettes.
“Once we endorse tobacco harm reduction, we hope that all those gadgets that we are using either e-cigarettes, vape or whatever other tactics for harm reduction, should be also regulated so that it won’t be free for all,” added the public health medicine specialist.
Dr Arifin Fii, president of the Advanced Centre for Addiction Treatment Advocacy (ACATA), sees vape’s “trade-off” as a pragmatic move.
“It’s a pragmatic approach where we allow good nicotine addiction, but we lower the harm. But we have to remember two things in THR. The first is that THR is for those we refer to as ‘recalcitrant smokers’ – smokers who either do not want to quit, or they are unable to quit.
“By adopting this approach, we allow nicotine addiction, but we minimise the harm. So, this is what we call harm minimisation.
“The second is that THR is not meant to replace tobacco control measures, but to complement tobacco control measures. It goes side by side,” said Dr Arifin, a general practitioner.
War On Tobacco Will Fuel Illicit Cigarette Trade
Dr Khafidz said an all-out war on tobacco products, including vapes, will only fuel the illegal tobacco trade, citing the effects of Bhutan’s blanket ban on tobacco products in 2004.
“As a practitioner on the ground, I treat a lot of drug addicts. They are all heavy cigarette smokers. What happens if we continue to push ahead with GEG 2007? I think there will be a boom in the illicit market to supply tobacco to the next generation, especially the young people who are affected by the GEG.
“As it is, the prevalence of illicit cigarettes in Malaysia is already high at about 60 per cent. So, if we carry on with GEG… Bhutan prohibited tobacco for eight years, but it allowed tobacco import with high tax. What happened? It resulted in high illicit cigarette trade.”
Bhutan enacted a national ban on the domestic sale, promotion, cultivation and distribution of tobacco products in 2004, and created a 100 per cent tax on small amounts of tobacco products legally imported into Bhutan for personal consumption. Those who used tobacco illegally were fined.
A World Health Organization (WHO) survey later revealed that the prevalence of smokeless tobacco in Bhutanese youth increased from 9.4 per cent in 2009 to 21.6 per cent in 2013.
The MSHR panel also criticised the government’s punitive approach in the GEG.
Dr Hussain urged Health Minister Khairy Jamaluddin to have “sympathy for our patients” and the next generation who will be affected by the GEG.
He said prohibitive approaches mooted in the GEG have been historically proven to fail, describing addiction as a form of “brain disorder” that needs certain processes before the person can fully stop the habit.
Dr Hussain added that the government’s proposed fines and jail terms to punish offenders of the tobacco law will bring more harm than good. He suggested community service instead.
“Eighty per cent of these smokers are among those who have poor income. If we don’t have an alternative to this prohibitive approach, those who have to serve a sentence, the effect of this is that their social mobility will be stopped.
“Those who are in school are forced to stop learning, those who are working are forced to stop earning. They are forced to go to jail for years instead of getting treatment,” said Dr Hussain.
He added that Malaysia’s move to criminalise tobacco use goes against global currents of decriminalisation.
“The war on drugs – how we deal with addiction – has proven to be a great failure. Now, while the whole world is moving towards decriminalisation, Malaysia is going against the currents.”