GENEVA, May 31 – A World Health Organization (WHO) tobacco control official has exhorted Malaysia to impose the same regulations on vape, e-cigarettes, and other novel products, as tobacco.
Dr Vinayak Mohan Prasad, the unit head of No Tobacco (TFI) at the WHO Department of Health Promotion, pointed out that while the world is focusing on vape or e-cigarettes, the rise in the use of other tobacco products have gone unnoticed, like water pipes and nicotine pouches.
“The problem is that there are multiple products; the focus should be on a very comprehensive approach to tobacco control, which will include control over the nicotine part,” Dr Prasad told CodeBlue in a recent interview at the sidelines of the 76th World Health Assembly in Geneva, Switzerland.
“If we don’t keep that in mind, then we end up in a situation where we promote product-specific regulations which can be very confusing for many reasons.
“Number one, it is not possible for the scientific community to keep running after the industry because they will keep reinventing their products.
“The addiction will stay. The governments will also be over-burdened with different strategies. So as a country, we have to make a decision – those who are party to the FCTC, and even those who are not but supported by WHO – is to look at all the evidence.”
The WHO tobacco control official stressed: “Please don’t treat e-cigarettes and nicotine products separately – put it as part of your tobacco control strategy.”
When asked to comment on the deregulation of liquid nicotine in Malaysia that enabled nicotine vape to be legally sold to anyone, including minors aged under 18, without any regulations whatsoever, Dr Prasad said: “Please bring in the regulations before you allow these products into the market.”
“You don’t want your children to have the same situation and fate as what many children face in so many other countries. Children are very quick to pick it up.
“The industry is using extremely smart ways to reach our children – the internet – not only the way they sell next to children’s stores or confectioneries, but the way they’ve been using influencers and getting into the internet space, the digital space, is amazing.
“Sometimes as regulators, we don’t even know – how quickly the industry is targeting different puff bars and another bar – they keep moving. These brands keep coming every three months. By the time the regulator comes to know, they have moved on,” added the WHO tobacco control official.
In a statement last May 24, the Vape Consumer Association of Malaysia (VCAM) called for separate legislation for vape products, instead of grouping them together with tobacco products in the Control of Smoking Product for Public Health Bill 2023. VCAM touted the harm reduction argument for vape, citing New Zealand as an example.
The landmark bill – which is expected to be tabled in the Dewan Rakyat next week and would be Malaysia’s first ever tobacco control Act if approved by Parliament – regulates both tobacco and vape products, including generational end game (GEG) provisions to ban all such nicotine products for anyone born from 2007.
CodeBlue reported Tuesday, however, that voting and passage of the controversial tobacco bill would likely be delayed, as Cabinet has decided to have the bill referred to a parliamentary special select committee (PSSC) after it is tabled in the current Dewan Rakyat meeting that is scheduled to end on June 15. The 2022 iteration of the tobacco bill, which had also been sent to a PSSC, never reached a vote in the House before the dissolution of the 14th Parliament for the 15th general election.
Malaysia’s Vape Market Poses ‘Threat to Singapore’
CodeBlue noted that the declassification of liquid nicotine in Malaysia has incentivised Chinese e-cigarette manufacturers to try to enter the Malaysian market, after a vape trade expo last May 13 in Kuala Lumpur that saw manufacturers from China tout their products to local distributors.
“It will put pressure on Singapore,” Dr Prasad remarked.
“Singapore is already worried. The Singaporean youth go to the Malaysian border; it’s a huge problem for border regulations – because they’re now trying to get to the Malaysian border and get hold of things which are not available. It’s a threat to Singapore,” added the WHO tobacco control official.
Singapore is among more than 30 countries that have banned vape.
Dr Prasad pointed out that countries like New Zealand, the United Kingdom, and Canada that “promote” or allow vape with regulations – based on the belief that e-cigarettes are less harmful than conventional cigarettes – are already “tobacco control champions” that have done “extremely well” in tobacco control.
Prevalence of current cigarette smoking among adults is 13.3 per cent in the UK, 10 per cent in Canada, and 9.2 per cent in New Zealand. Malaysia’s current smoking rate among adults (aged 15 and above) was 21.3 per cent in 2019, the latest data available.
Malaysia’s GEG proposal was modelled after New Zealand that passed an anti-smoking amendment bill last December, banning the sale of smoked tobacco to anyone born from 2009 (vape products, however, were excluded from New Zealand’s historic legislation).
Dr Prasad said WHO’s recommendation to countries was to ban vape or e-cigarettes if these products can’t be regulated. “And when you regulate it, you don’t make a distinction between tobacco and this product because you want to protect your children.”
The WHO tobacco control official added that if 50 countries were to ban vape, it would become the “global normal”, describing the current figure of 30 plus as a “good number”.
“You have to follow the norm, right?” Dr Prasad said. “Just because I come from an Asian country or an African country, I banned it, you don’t want to listen to me. Just three countries are promoting it, 30 are banning it, should I not listen to the 30?”
He added that Singapore and India, which have banned vape, are also tobacco control champions.
“Today, the champions for tobacco control are not just limited to three or four developed countries. There are a lot of champion countries in Africa now. Sierra Leone has the most comprehensive legislation on tobacco and nicotine products passed last month, including on e-cigarettes. Look at Ugandan law – very comprehensive,” Dr Prasad said.
“Many of these countries have banned it.”
Elimination Level Is 5% Smoking Prevalence (for All Products), Plus Declining Adult and Youth Smoking Rates
Dr Prasad said the WHO currently does not provide “tobacco-free” certification for countries. Five per cent smoking prevalence is not a target set by the United Nations body.
“But public health experts and end game strategies have identified that 5 per cent is the kind of elimination level which you’re getting, still cannot be free, but elimination level.
“It should be both adults and youth [rates] that should be declining consistently. It cannot be adults declining, but youths are not declining. Both have to be consistently declining to 5 per cent or less.
“And it should cover all products,” Dr Prasad added. “It cannot [only] be tobacco; it has to be nicotine. Then only you can achieve elimination level.”
Malaysia’s National Health and Morbidity Survey (NHMS): Adolescent Health Survey 2022 by the Institute for Public Health at the Ministry of Health (MOH) revealed a significant increase in the prevalence of current e-cigarette and vape use among Malaysian teenagers aged 13 to 17, from 9.8 per cent in 2017 to 14.9 per cent in 2022. Current cigarette smoking rates in this adolescent group dropped in the same period from 13.8 per cent to 6.2 per cent.
The main NHMS 2022 has yet to be released.
‘Switching is Not Quitting’
When CodeBlue pointed out that health authorities in New Zealand and England say that vaping is less harmful than smoking tobacco, Dr Prasad responded: “Compared to what?”
“The point is – it is less harmful compared to what and to who? If, at the end of the day, I have a society where I have 10 new children getting addicted to nicotine – is that less harmful to the society?
“If out of 100 adults, 40 are able to use e-cigarettes and switch – is that less harmful? Because half of them are still smoking cigarettes.”
Dr Prasad said if countries cannot ban vape or e-cigarettes, one strategy would be to ban flavours because these are what attracts children to such nicotine products.
“The adult smoker who wants to quit, and is not able to quit using the proven evidence-based solutions, which are nicotine gum and patches, and quit line counselling and behavioural counselling approaches, medications – varenicline, bupropion – if they are not able to quit using those solutions, and they are able to quit using e-cigarettes, they should. But they do not need flavours for that.”
The WHO tobacco control official, however, added a caveat: “Switching is not quitting.”
Dr Prasad said people need to be completely free of nicotine addiction.
“It cannot be that, ‘oh I stopped smoking, but now, instead of smoking 10 cigarettes, I use two cigarettes when I can, and then I do e-cigarettes. That’s dual users,” he said.
“Somebody has to quit successfully. A good success is – look at six months – [they] shouldn’t be using any form of nicotine or tobacco products after they quit.”
He cited harms from e-cigarettes, such as to the foetus’ brain development for pregnant women, as well as damage to lungs with “popcorn lungs” from long-term use, and the potential for adulteration or manipulation of e-cigarettes that leads to e-cigarette or vaping use-associated lung injury (Evali).
“Evali – the injuries happened mostly to children in the US three years ago. But it’s not ending. Injuries are happening in Russia, just a couple of weeks ago, [and are] continuing to happen in a number of countries, off and on,” Dr Prasad said.
“It’s because the children are able to manipulate the device and put different combinations, including narcotics. But it’s not a challenge of narcotics; it’s a challenge of the way the chemicals and ingredients are being mixed.”
FCTC Applies To Vape/ E-Cigarettes Within Tobacco Control Context
CodeBlue asked Dr Prasad – one of the architects of the WHO Framework Convention on Tobacco Control (FCTC) Protocol – if Malaysia’s deregulation of liquid nicotine violated the WHO FCTC, the first international public health treaty that entered its 20th anniversary this year, which Malaysia ratified in 2005.
Today is World No Tobacco Day.
Health Minister Dr Zaliha Mustafa gazetted last March 31 an order to remove liquid and gel nicotine from control under the Poisons Act 1952, enabling the government to tax e-cigarette and vape liquids with nicotine from April 1.
“The Conference of the Parties (COP) to the FCTC is the highest decision-making body. Malaysia is part of that. There are many judgments or decisions by the Conference of the Parties, including on e-cigarettes,” Dr Prasad said.
“It essentially means, don’t try and regulate it without the context of tobacco control. As soon as you have that, all the provisions of the FCTC will need to apply – Article 5.2 says that you have to regulate these products, whether it’s tobacco or nicotine.”
Article 5.2 of the FCTC states that member parties, in accordance with their capabilities, shall develop appropriate policies for preventing and reducing tobacco consumption, nicotine addiction, and exposure to tobacco smoke.
Recommended Vape Regulations, Environmental Legislation to Bill Industry for Cigarette Butt and Disposable E-Cigarette Pollution, Additional Levies on Industry
In 2016, the seventh session of the COP adopted a decision to invite member parties to “consider” applying regulatory measures – like those listed in a 2016 WHO report on electronic nicotine delivery systems (ENDS) and electronic non-nicotine delivery systems (ENNDS) – to prohibit or restrict the manufacture, importation, distribution, presentation, sale, and use of ENDS/ ENNDS, as appropriate to their national laws and public health objectives.
The WHO report suggests regulatory measures for ENDS/ ENNDS that can be adopted by countries, such as banning sale and distribution to minors; banning possession by minors; banning or restricting advertising, promotion and sponsorship; introducing taxation; banning or restricting the use of flavours that appeal to minors; and regulating places, density, and channels of sales.
Countries may also prohibit by law the use of ENDS/ ENNDS in indoor spaces or at least where smoking is not permitted. Other regulatory measures proposed by the WHO for vape or e-cigarettes include requiring health warnings about potential health risks, prohibiting claims about the effectiveness of ENDS/ ENNDS as smoking cessation aids unless approved by a specialised government agency, and raising awareness about potential industry interference with countries’ tobacco control policies.
Even if Parliament passes the Control of Smoking Product for Public Health Bill, the government will still need to enact specific regulations under the Act that may take months before coming into effect.
Malaysia currently has zero regulations on vape or e-cigarettes, as tobacco control regulations under the Food Act 1983 exclude these products. The March 31 delisting of liquid nicotine effectively legalised the sale of nicotine vape, enabling e-cigarettes to be sold to anyone, including children and teens aged under 18, without any sales restrictions; designated vape-free places; restrictions on advertising, promotion and sponsorship; or requirements for health warnings on vape packaging and labeling.
Dr Prasad suggested that Malaysia, for a start, introduce regulations on e-cigarettes like vaping prohibitions in public places; bans on advertising, marketing and sponsorship; and prohibitions on unproven health claims.
“The simplest is – the current tobacco regulations must apply [to vape],” he said. “The gains in tobacco control cannot be lost. We want to save lives.”
The WHO tobacco control official also suggested that Malaysia introduce tobacco and vape-related environmental legislation, like that in Spain, that charges tobacco companies the cost of cleaning up cigarette butts discarded by smokers in public spaces.
“Malaysian cigarette use is still very high. So this one will lead to more than US$50 million (RM230 million) to US$70 million (RM322 million) from the industry every year, even more. That’s a lot of money. And don’t exclude disposable e-cigarettes. Go for it,” Dr Prasad said.
“Malaysia has got all its tourism in place. You don’t want to spoil your beaches; you don’t want to spoil your tourism.”
Dr Prasad further suggested imposing additional levies on tobacco companies – separate from tobacco taxes – like what is done in Vietnam and Kenya.
In 2013, the Vietnam Steering Committee on Smoking and Health (Vinacosh) established a Fund for Prevention and Control of Tobacco Harms that is funded by compulsory contributions from tobacco manufacturers and importers.
Kenya requires tobacco manufacturers and importers to pay an annual solatium compensation contribution (which is compensation for harm suffered) at 2 per cent of the value of the products manufactured or imported to fund tobacco control research, cessation, and rehabilitation programmes.
“All of these are additional costs which the government levies on the industry, depending on the market share, not on tax,” Dr Prasad said.
He added that Vinacosh and Thai Health, a health promotion government agency in Thailand, are funded by the earmarking of tobacco taxes. ThaiHealth’s website states that the agency receives annual revenue of about US$120 million (RM552 million) from 2 per cent of excise taxes on tobacco and alcohol.
Meanwhile, tobacco control programmes in Kenya and the United States are funded by annual levies on tobacco companies based on their market share.
Dr Prasad pointed out that a whopping 1,200 people work solely on tobacco in the US’ Food and Drug Administration (FDA).
“The US market share model gives them the revenue potential. Then it allows them to oversee all the companies, all the brands, testing ingredients, testing products, marketing strategies – they have the whole capacity to do it.”
