KUALA LUMPUR, April 13 – Following the delisting of liquid and gel nicotine from the Poisons Act 1952, parents are now left with the responsibility of preventing their children from becoming nicotine addicts until new regulations are introduced to govern these products, health experts say.
Galen Centre for Health and Social Policy chief executive Azrul Mohd Khalib said parents must now have frank and open conversations with their children about nicotine, following the government’s move to exempt nicotine from control under the Poisons Act.
Azrul said those seeking to quit smoking should also find support from others who are trying to quit smoking, rather than turning to alternative nicotine delivery methods as replacements.
“Well, for myself, regarding the earliest scenario involving children, parents should have an honest and open discussion with them. Chances are, if they are teenagers, they may already be starting to vape or have already picked it up. It’s important not to be judgmental.
“It’s hard [to do], but it’s something we need to do to be able to ensure that our kids are able to know and make good decisions.
“The government is basically saying, ‘The ball is in your court. It’s your responsibility, figure it out and take care of your kids’. So that’s going to be the burden that we have until there is a piece of legislation that gets passed,” Azrul said in a recent BFM public health podcast on nicotine, vaping and taxes.
“For those who are trying to quit smoking, there are methods that have been demonstrated to work like nicotine replacement therapies, gum, syrup and so forth, that work. But I think what is most important is to get the support that you need to quit smoking, and that more than anything works having people around you who are facing the same kind of problem to be able to deal with the addiction, and most importantly, get medical assistance in that.”
Dr Murallitharan Munisamy, the managing director of the National Cancer Society Malaysia (NCSM) and a fellow participant in the podcast, echoed Azrul’s views. However, he stressed the critical need to address the root mental health issues that can drive young people towards nicotine addiction.
Dr Murallitharan highlighted the experiences of addicted adolescents and young adults in Australia and emphasised that parents in Malaysia should foster an open dialogue with their children or provide guidance to mental health professionals. He noted that many young people in Australia turn to nicotine as a coping mechanism, contrary to the erroneous belief that it is merely an attempt to appear fashionable or popular.
“I think we also need to get into this idea of large-scale mental health interventions because people are turning to cigarettes or vaping as a form of stress relief or coping mechanism. We need to address the coping problem then or the stress.
“And those are things that we can do behaviorally, like open up to our kids a little more, like speak to them, get them to speak to us, or to someone who’s a mental health professional – to kind of decongest that amount of stress or the need for them to actually cope via the use of these devices,” said Dr Murallitharan.
In Australia, it is illegal in all states and territories to supply nicotine vapes, possess or use them without a prescription. Despite these restrictions, the Public Health Association of Australia (PHAA) reports that an estimated 11 per cent of 16-to-24-year-olds regularly vape, almost double the number from 2019 to 2020.
Some suppliers have found ways to circumvent the law by removing “nicotine” from their ingredients list, even though the substance is still present in the product. This has led to many children unknowingly becoming addicted to nicotine, while others have been able to purchase vapes without age verification through “cheap servos”.
Teenagers in Australia have urged the government to help them break their addiction, as the country faces tightening laws to protect young people.
Dr Murallitharan expressed concern about whether the upcoming parliamentary meeting, which will only last 11 days, will provide enough time for Health Minister Dr Zaliha Mustafa to successfully table the “new” Control of Smoking Product for Public Health Bill 2023 and pass it into law.
“There have been, I mean, not us, we’re not that old, but they are colleagues of us in tobacco control who have been trying to table a Control of Tobacco Product Act for more than 40 years.
“So, I’m a bit pessimistic until it comes up to the second reading and gets passed. Whether it will actually go on the floor first, there’s kind of a big pessimism amongst all of us. And if it does pass into law, good on them, but I’m really very pessimistic about it,” said Dr Murallitharan, who is also chairman of the Malaysian Council for Tobacco Control (MCTC).
On March 31, Dr Zaliha utilised her ministerial authority to exempt liquid and gel nicotine from the Poisons Act’s list of controlled substances, despite unanimous opposition from the Poisons Board.
As a result, starting from April 1, a 40 sen per ml excise duty was imposed on e-liquids containing nicotine, and local vape manufacturers were granted until the end of the month to register with the Customs Department.
Vape: The New Gateway To Nicotine Addiction
According to Dr Murallitharan, a recent study revealed that around 70 per cent of those who have taken up vaping had never smoked cigarettes.
On the other hand, Azrul compared the demographics of vaping and smoking using industry data and found that while approximately 50 per cent of males smoke, only about 1 per cent of females smoke. However, when it comes to vaping, about 68 per cent of users are male and 32 per cent are female. This shift in the gender distribution between the two industries suggests a change in trend, according to Azrul.
“I think it’s useful for us to compare against the number of smokers. And when we look at the number of smokers, we know from the same survey Dr Muralli cited just now that there are around 7 million smokers. And if you look at the breakdown in terms of the profile, and this is where it gets very worrying, because when you look at industry data, we look at who is vaping and who is smoking.
“When you look at who’s smoking, half of all males smoke. So it’s like around 40 something per cent; women, it’s like around one per cent, smoking. But for vape, from industry data itself, we find that around 68 per cent are male while 32 per cent are women.
“So, we are actually seeing, and this is again, based on the industry’s own data, a significant increase, or a trend, if you like, of more and more young women who are taking up vaping, but they’re not taking up smoking, but they’re taking up vaping and e-cigarettes.
“And that’s something that needs to be considered. And especially, since many of them are adolescents or young adults in a category,” Azrul said.
Dr Murallitharan suggested that this shift in trend could be attributed to the way e-cigarettes and vape products are perceived by the public.
During the podcast, both experts expressed their deep concern regarding the branding of these products as a safer alternative to traditional cigarettes and a form of harm reduction.
The harm reduction argument posits vape and e-cigarettes as a safer alternative for those wishing to quit smoking. The United Kingdom’s National Health Service (NHS) notes that e-cigarettes do not contain two of the most harmful elements in tobacco smoke: tar and carbon monoxide.
While the liquid and vapour may contain some potentially harmful chemicals that are also found in cigarette smoke, they are present at lower levels.
Dr Murallitharan pointed out that in Malaysia, many people who do not smoke have turned to e-cigarettes and vape, believing them to be a safer alternative to traditional cigarettes.
However, this assumption overlooks the fact that nicotine, the main component of e-cigarettes and vape, is highly addictive and potentially harmful. This, he believes, is a major public health issue in Malaysia.
“So, with the idea that it is being branded as being safe that just entails a lot more people to say, ‘Hey, why not? I can now use this as a mechanism to release stress’, or ‘Why don’t I just try it since it’s not as bad?’
“And that’s where this is now becoming a worrying phenomenon because there are two things that you need to consider, not within vaping itself, but within nicotine. Which is: one, nicotine by itself, it’s a highly, highly, highly addictive substance. It’s on the same kind of addictive level as heroin or cocaine.
“Nicotine, it leaves you with this dependency. What’s also, on the other hand, really bad about nicotine is there’s a lot of harm that is becoming more and more obvious with nicotine as more and more evidence comes up.
“Nicotine by itself causes heart issues, cardiovascular issues, brain issues, gastrointestinal issues. And now we are finding this newer data, as a lot more people are using, that is causing cellular mutations as well, which inevitably lead to cancer as well by itself.
“Leave conventional cigarettes aside, nicotine is a substance now we are proving it to be more and more a driver of mutation. So, combine this together, we are getting people who become addicted to a substance that’s causing them harm.
“This is the public health problem,” said Dr Murallitharan.
Azrul challenges the notion of e-cigarettes and vape as a harm reduction method for smoking cessation, arguing that smokers who switch to vaping often do not quit smoking but continue with their addiction through vaping, perceiving it as a less harmful alternative. Rather than promoting cessation, Azrul noted that there is a growing trend of dual users, who smoke both traditional cigarettes and vapes.
“Basically you’re saying that if one smoker decides to take vaping, there is one less smoker. And that number shifts to the number of vapers in the country, but actually, what we are seeing, and this is from more and more cases that are coming into the quit smoking clinics which are treating people for nicotine addiction, is that you are seeing more and more people who are coming in who are dual users.
“They are both smoking and they’re also using vape. And the common denominator here is basically nicotine addiction. And so you find that rather than dealing with the issue of nicotine addiction, we are seeing an exacerbation of this type of addiction in the country, a dual epidemic as it were.”
With the delisting of nicotine, the sales and purchase of nicotine is a free-for-all with some Bazaar Ramadhan even selling vape products, according to Dr Murallitharan. He said due to the lack of correct perception around liquid and gel nicotine, the public may not fully understand the risks associated with it, leading to an increase in the number of users.
“Everyone and anyone can sell vaping products containing a nicotine gel or liquid. So, you could buy it off in 7-11, for example, or any other commercial store you could buy it off. Bazaar Ramadhan, which now sells vape. The one near my house has at least an equivalent number of vape stalls as there is the number of kuih stalls as well. It’s quite impressive.
“And what happens then is rather than vape being available for people with nicotine addiction, everyone now has the opportunity to try, taste, smell, and use it, and it’s just something that everyone tries to use because of this perception, ‘Hey, why don’t I try it, it’s safe’.
“So now with all those controls gone away, some of my colleagues from CAP (Consumers’ Association of Penang) and again, we can see that in the newspapers every day, CAP is basically running a social experiment where they’re getting kids to see whether they can buy [vape]. They [children] can buy anywhere,” said Dr Murallitharan.
MOH Has No Widespread Anti-Vaping Programmes
When asked about the effectiveness of anti-smoking and anti-nicotine educational programmes, Dr Murallitharan stated that the Ministry of Health (MOH) currently does not have any specific programmes in place to educate the public about the dangers of nicotine or vaping.
“We don’t have an anti-nicotine specific programme. Short answer: We don’t have any kind of programmes for anti-vaping, not in any kind of widespread manner pushed out by the MOH.”
With the absence of regulation, the easy accessibility, and insufficient public awareness on the hazards of nicotine, Malaysia is likely to witness an increase in nicotine poisoning and other health problems.
Azrul also highlighted the creative nature of Malaysians and drew a parallel with Americans who have been found to adulterate vape juices with various substances, such as alcohol and vitamin E acetate, resulting in severe harm to users.
“Adulteration is one of the biggest worries right now. In other countries, you have people putting in things like THC (Tetrahydrocannabinol), increased alcohol instead of propylene glycol, vitamin E acetate, all of which can cause severe harm to patients.
“In severe cases, it can lead to things like nicotine poisoning, which, mark my words, we are going to hear more about. And of course, EVALI, which is e-cigarette or vaping associated lung injury, and things like popcorn lung, and all of this,” Azrul said.
“We haven’t seen them over the past couple of years because we have the most minimum of safeguards. But it was enough to prevent the prevalence of these cases from popping up. But now with no safeguards, which is the current status quo, today, you are going to see a lot of this appear.”