We read with great interest the article on “Regulating Vape: What Malaysia Can Learn From Other Countries” by Liu Hai Kuok.
Following the delisting of liquid and gel nicotine from the Poisons Act, many health advocates have questioned the Health Minister’s decision to subject Malaysia’s vaping community to lawlessness, where the purchase of e-cigarettes by minors is made legal, but the Control of Smoking Products for Public Health Bill 2023 is yet to be passed.
We applaud the timeliness of policy prescriptions from public health advocates, given the current lack of regulations. Nonetheless, we opine that the analysis by Liu may be incomplete.
Education
We do not oppose education. We argue that it is necessary, but not sufficient to tackle the smoking pandemic.
Given at least two-thirds of Malaysian adolescents who use e-cigarettes or vapes have tried a cigarette before the age of 14 years old, as revealed by the National Health & Morbidity Survey: Adolescent Health Survey 2022, it is obvious that those who smoke started smoking while they were in the education system.
In addition, it is unlikely that smokers are completely unaware of the harmful effects of smoking cigarette or e-cigarette. Hence, even if the quantity and quality of smoking education campaigns are increased and improved, there are at least three limitations to relying on education alone.
Firstly, the reasons behind smoking are complex and varied. While providing information about the risks and health implications is essential, it does not address the broader sociocultural, psychological, and environmental factors influencing an individual’s choices.
Secondly, adolescents are particularly vulnerable to the allure of e-cigarettes and tobacco products due to peer pressure, attractive packaging and flavours, or just out of pure curiosity.
Finally, education alone is unlikely to overcome the physical addiction to nicotine. Addiction involves complex neurobiological mechanisms that create a compulsion that expands beyond mere knowledge.
The 2020 study by the United States Preventive Services Task Force concluded with moderate certainty that primary care–feasible behavioural interventions, such as education or brief counselling, to prevent tobacco use in school-aged children and adolescents have only a moderate net benefit. Therefore, strategies beyond education are needed to bridge the knowledge-behaviour gap.
Regulations
Despite implementing bans of varying degrees on the sale, purchase and use of e-cigarettes and vape in different countries, it is a fact that they remain available to adolescents.
However, we argue that the lack of enforcement leading to its failure does not warrant the removal of regulation altogether.
While it is still early to tell the effect of delisting of liquid and gel nicotine from the Poisons Act on e-cigarettes and vaping use among Malaysian adolescents, it is logical to assume that the widespread unregulated availability of e-cigarettes and vape will cause a rise in their usage just because it is “legally allowed”.
Nonetheless, the best available evidence does not indicate banning as a one-size-fits-all solution. A 2019 study found that the provincial bans on e-cigarette sales to minors in Canada was associated with a significant reduction in the rate of increase in e-cigarette use by minors, but banning alone could not reverse the overall increase in e-cigarette use.
Whether a complete prohibition on the use of nicotine products such as the Generational End Game, or selective bans on flavours preferred by adolescents, nicotine content cap, or minimum legal age, current evidence points to the merits of legal interventions in public health problems – the recent example being the role of movement control orders in curbing the Covid-19 pandemic.
Therefore, while we search for the e-cigarette and vape panacea, we can employ the best available solutions, including education, bans, pharmacotherapy for addiction, and behavioural science-based interventions.
Conclusion
On tackling the growing e-cigarette and vape pandemic, there needs to be a multi-prong approach rather than a dichotomous one. In other words, education and bans are equally necessary, complement each other, and are only two strategies among many more.
To name a few, regulating the following: marketing and packaging; promotion on social media; use of influencers; sponsorship of youth events; all broadcast, print and digital advertising; and the density of vape shops in different localities, as well as prohibiting the mailing of e-cigarettes through courier services are some strategies that have not been fully explored in Malaysia.
While we do not yet know the best way to solve such a large problem, here’s what we know: studies have found strong and consistent evidence of an association between initial e-cigarette use and subsequent cigarette smoking initiation among adolescents and young adults.
Therefore, we advocate for a public health response rather than a punitive response.
We advocate for the continuous and strict implementation of traditional tobacco control measures such as taxation, price hikes, and clean indoor air policies.
We advocate for a smoke-free Malaysia.
Dr Roslina Abdul Manap is a consultant respiratory physician and former president of the Malaysian Thoracic Society. Dr Ginsky Chan is trained in public health and is the medical director of Angsana Health.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
