Liquid Nicotine Delisting ‘Backward’ Step For Malaysia, Say UM Public Health Students

Universiti Malaya postgrad public health students condemn the declassification of liquid nicotine as a “backward” step for Malaysia, as Singapore, Thailand, Brunei, and 34 other countries have banned vape to protect the young from nicotine addiction. “First do no harm,” they say.

KUALA LUMPUR, April 7 — Malaysia’s declassification of liquid nicotine to legalise e-cigarettes – amid the absence of regulations – is regressive compared to neighbouring countries that have banned vape, Universiti Malaya (UM) postgraduate public health students said today.

The Master’s students from the top public university in the country criticised the exemption of liquid and gel nicotine from the Poisons List under the Poisons Act 1952, as this was done without any regulations in place to restrict the sale, advertising, promotion, and use of the “poisonous material” in the market.

“This also represents a backward step compared to neighbouring countries, such as Singapore, Thailand, Brunei, and the 34 other countries that have placed a total ban on vape to protect their citizens, primarily the younger generation, from nicotine addiction,” said Oui Hui Che, a pharmacist and member of the Universiti Malaya Public Health Master’s Students’ Movement, in a press conference held at the university here today.

“We, as medical officers and allied health workers, adhere to the ethics of ‘First do no harm’,” she added, referencing the Hippocratic Oath for doctors.

“We support the advice of the Poisons Board, who have unanimously disagreed with this action which simultaneously threatens the life and safety of all Malaysian citizens, primarily children and youths that is the nation’s continuing generation.

“We also call for the bill on the control of cigarettes and vape and the generational end game (GEG) provision be presented in Parliament and passed as quickly as possible.”

Last Tuesday, Prime Minister Anwar Ibrahim maintained the government’s commitment to tabling the “new” Control of Smoking Product for Public Health Bill 2023 in the upcoming parliamentary meeting next month that will only be 11 days long. 

Health Minister Dr Zaliha Mustafa exercised her ministerial powers to exempt liquid and gel nicotine from the list of controlled substances under the Poisons Act last March 31, overruling unanimous objection from the Poisons Board against the proposal. 

Excise duty of 40 sen per ml on e-liquids with nicotine came into effect last April 1, with local vape manufacturers given until month’s end to register with the Customs Department.

The importance of regulating liquid and gel nicotine is of paramount importance to the UM students’ group that delved into the side effects from nicotine addiction.

“The side effect of nicotine on the dopamine pathway in our brain is it will cause addiction. When there is addiction, there will be side effects that are increased heart rate, it will increase your blood pressure. When this happens, it can also cause the hardening of the blood vessels and can ultimately lead to CAD (coronary artery disease), diabetes, and et cetera,” said Dr Jeshua Navaraj, a member of the students’ group, at the press conference.

“Therefore from the perspective of public health, the exclusion of liquid and gel nicotine is the main issue.”

Based on the press statement released by the UM students’ group, nicotine poisoning – caused by high levels of nicotine in the body – has lately become a growing concern, as nicotine concentration in e-cigarettes and vape is higher than tobacco products.

Both the National Institute of Occupational Safety and Health (NIOSH) and the Centers for Disease Control and Prevention (CDC) from the United States say the lethal dose of nicotine inhalation for an adult weighing 70kg is 50 to 60 mg/kg. 

For children, the American Academy of Pediatrics stated that a single teaspoon of liquid nicotine is enough to kill an 11 kg child. Nicotine which comes into contact with the skin can become poisonous in a matter of minutes. 

“Nicotine is a chemical substance that is easily absorbed into the body. It can be absorbed into the body through the skin, inhaled into the lungs, and through the mucous membranes of your mouth and intestines,” said the statement by the UM Public Health Master’s Students’ Movement.

According to the Master’s students, there are two stages of nicotine poisoning: early and late. 

In the early stages of nicotine poisoning, an individual can experience headache and nausea, increased salivation, stomachache, sweating, increase in blood pressure and heart rate, quick and laboured breathing (hyperpnea), complete loss of movement control (ataxia), loss of balance, difficulty in walking, shivering, muscular twitching, and convulsions. 

In the late stages, symptoms of late nicotine poisoning include diarrhoea, hypotension and a slower than normal heart rate (bradycardia), abnormal heart rhythm, shock, coma, muscle weakness or paralysis, shallow breathing, difficulty in breathing, and respiratory failure. 

Burden Of Disease Outweighs Tax Revenue From Vape

Speaking with CodeBlue after the press conference, Dr Jeshua stated that the numerous elective properties of nicotine could also result in an individual being diagnosed with dementia and cognitive decline. 

“So public health as a whole, for example, from diabetes to hypertension, to coronary artery disease, kidney, kidney disease, your cancers – everything goes back to nicotine,” he said.

“Everything goes back to the hardening of your vessels. And this is when you’re controlling it at 18 years old, you. Once it’s [liquid nicotine] off the [Poisons] Act, for example, if a six-year-old kid has access to it, and he’s addicted to it, the side effect that he’ll be experiencing once he’s 18 years old and above, he’ll be exposed to it even before that. That is why we think it’s a public health concern now.” 

In addition to this, Dr Jeshua also stated that nicotine addiction could lead to many socio-economic issues, especially with children being addicted to cigarettes at a very young age. 

“For example, if you are starting to smoke at 18, your addiction starts at 18. But if you start to smoke at six, you’re going to be a nicotine addict since you’re six years old. 

“There is documented evidence that nicotine has direct implications on. First, the child being absent from school, crime, because they can’t buy cigarettes, and that leads to a cascade of events,” he said.

“Secondly, with the dysregulation of the dopamine centre, there’s an imbalance in the reward centre in the brain. When there’s an imbalance in the reward centre in the brain, this decreases the person’s performance as a whole.

“So, if a child has an affected dopamine centre or reward centre in the brain at a young age, overall, we are talking about a generation of kids or working-class people that will have decreased productivity and that will definitely have an effect on the national income, GDP and so on. 

“If you think that implementing this tax would bring you some certain amount to the economy, I think the burden of disease far outweighs the tax that you’re going to get from this removal of liquid and gel nicotine from the Poisons Act.” 

With the predicted rise in health issues following expanded access to e-cigarettes and vape from the delisting of liquid nicotine, the UM public health students’ group held that the country does not have the needed medical facilities nor the staff to meet the estimated growth in the number of patients. 

Dr Jeshua, representing the group, informed the members of the press that in 2019, Malaysia recorded 154 government hospitals and 250 private hospitals, meaning, on average, there are 1.89 hospitals per one thousand people. This, said Dr Jeshua, places Malaysia behind the global average. 

“So, if our population is growing by 1.1 per cent and they have increased accessibility to nicotine – which is below the age of 18 – which will indirectly cause the diseases to increase, we are talking about the existing health facilities not being able to accommodate this number of patients.” 

On the topic of health care workers, Dr Jeshua held that despite exceeding the World Health Organization’s (WHO) Sustainable Development Goals (SDGs) of one health care worker for every 225 people, Malaysia still might not be able to meet future medical needs from a projected rise in disease related to smoking or vaping.

“With the population increase of 1.1 per cent and our economy, which is growing three to four per cent a year on average, and these existing issues in the MOH (Ministry of Health) in terms of infrastructure, health care workers, and budget – not only the MOH but our government as a whole – we feel that the exclusion of liquid and gel nicotine from the Poisons Act will result in the present number [of vapers] to increase [to a number] far worse than it is now.” 

Dr Victor Hoe Chee Wai Abdullah from UM’s Department of Social and Preventive Medicine said that though UM supports its students, the press conference and views expressed in the press conference belong solely to the students, and not the department or the university. 

“In Universiti Malaya and all public universities in the country, we should encourage our students to be vocal on the subject or to advocate on the subject that they are concerned about,” Dr Hoe told reporters at the sidelines of the press conference.

“And today’s press conference is actually 100 per cent the work of our students. It is not the work of the department, but the department supports the work and the department provides guidance and guidelines on how to engage with the press.”

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