MCTC Links Rise In Teen, Adult Nicotine Poisoning In Malaysia To Vape

MCTC says Malaysia’s trend in nicotine poisoning has shifted from under-5 children before 2021 to now increasing among teenagers and adults, attributing this shift to the rise of e-cigarette and vape use by youths. EVALI is also challenging to diagnose.

KUALA LUMPUR, Nov 17 – Nicotine poisoning is on the rise among teens and adults in Malaysia, according to Malaysian Council for Tobacco Control (MCTC) president Dr Murallitharan Munisamy.

In an affidavit filed on October 19 in the High Court here, Dr Murallitharan highlighted a shift in the trend of nicotine poisoning cases, with an increase among teenagers and adults in the country.

Historically, most nicotine poisoning cases from 2015 to 2021 involved children aged five and below. These cases typically resulted from toddlers ingesting e-liquids or vape juices containing 30 to 50mg/ml of liquid nicotine.

However, the trend has since shifted, with the National Poison Centre reporting 41 cases of nicotine poisoning among teenagers aged 15 and above, comprising 42 per cent out of a total 97 cases, as of September 2023. Dr Murallitharan attributed this shift to the increased use of electronic cigarettes and vaping among teenagers in Malaysia.

“I also say that in line with the increase in the use of electronic cigarettes and vape among teenagers in Malaysia, there is an increase and change in the nicotine poisoning trend. The trend has changed to receive more cases that involve teenagers and adults that vape.

“Among the symptoms that are frequently reported are vomiting, fainting, and convulsions that are suspected as a result of exposure to too high a nicotine dose from vape in the form of a pod which there are many in the market,” said Dr Murallitharan.

Dr Murallitharan’s affidavit is part of a lawsuit filed against the health minister by MCTC, the Malaysian Green Lung Association (MGLA), and Voice of the Children (VoC) challenging the declassification of liquid and gel nicotine used in e-cigarettes and vaporisers as a scheduled poison from the Poisons Act 1952.

A Facebook post by the National Poison Centre outlines the e-cigarette situation after the health minister’s decision to delist liquid nicotine from the Poisons List. 

It claimed that the move has led to uncontrolled nicotine levels in vape liquids, resulting in e-liquids containing more than 50 to 60 mg per ml of nicotine. The average amount of nicotine found in the market ranges from 20 to 50mg/ml or two to five per cent. 

Additionally, the Poison Centre reported a case involving a 9-year-old habitual vaper who was hospitalised after vaping a new flavour, experiencing shortness of breath, vomiting, high fever, and whole-body rashes.

Another 9-year-old case reported by the Poison Centre involved a child hospitalised after four consecutive days of vaping their uncle’s high-nicotine disposable vape. The child had acquired a liking for the banana milk flavour of his uncle’s high-nicotine disposable vape. 

Dr. Murallitharan then referenced Dr Zaliha’s statement in the Dewan Rakyat Special Chambers last June 23, highlighting the health minister’s awareness of e-cigarettes/ vape dangers on young individuals. 

The health minister, using the same National Poison Centre statistics, affirmed MOH’s awareness and monitoring of vape-related diseases until 2022. Dr Zaliha had acknowledged that five out of seven cases of nicotine poisoning that year involved children.

Despite being aware of the negative impact of delisting liquid and gel nicotine on the nation and youth, the health minister maintained and defended her decision to remove the highly addictive substance from the Poisons List.

In her affidavit filed in the High Court on October 5, Dr Zaliha asserted her authority as health minister, stating that she exercised her right to remove liquid and gel nicotine from the Poisons List without approval from the Poisons Board and that she only needed “consultation” with the Board. 

Dr Murallitharan said, contrary to the statement made by the health minister, that Dr Zaliha did not “consult” with the Poisons Board during its meeting last March 29. 

“The respondents have failed and/or negligent to take into account the relevant factors such as the dangers of the liquid gel and nicotine alongside the e-cigarette and vape before making the Poison Order (Poison List Amendment) 2023. 

“As an explanation and answer to paragraph 6(c) the Respondent’s Answer Affidavit (1), I have been informed by the members of the first applicant including organisations that have been represented in the Poison Board and truly believe that the first respondent has not ever consulted or discussed, whether it be physically or online with the Poison Board on March 29, 2023.”

EVALI Challenging To Diagnose, With Many Cases Misdiagnosed

Dr Murallitharan said that non-respiratory symptoms can complicate the diagnosis of e-cigarette or vaping use-associated lung injury (EVALI). 

Symptoms such as nausea, vomiting, palpitations, headaches, and fever contribute to the diagnostic challenge, leading to numerous misdiagnoses. As a result, reported EVALI cases may be significantly lower than the actual incidence.

The American Lung Association defines EVALI as the term for the increasing cases of severe lung illnesses associated with the use of e-cigarettes or vaping products.

A report from the Centers for Disease Control and Prevention (CDC) examined bronchoalveolar lavage (BAL) fluid from EVALI patients across 16 states, comparing it to fluid from healthy individuals. 

Vitamin E acetate, also found in FDA and state-tested product samples, was identified in the BAL fluid of 48 out of 51 EVALI patients, while none was found in healthy individuals.

In addition to vitamin E acetate, ongoing investigations into vaping materials explore various substances and product sources as potential causes.

Dr Murallitharan stated that propylene glycol and vegetable glycerine, considered safe for oral consumption, become pulmonary irritants when inhaled. When heated in e-liquids, these compounds transform into carcinogenic carbonyl. 

The level of carcinogenic compounds produced depends on the solvent and battery output voltage of the vaporiser, with high-voltage e-cigarettes posing a risk of exposing users to elevated levels of carbonyl compounds.

“There is no data related to whether the flavouring agents are safe when exposed through inhalation.”

Dr Murallitharan, referencing an article titled “Metal Concentration in e-Cigarette Liquid and Aerosol Samples: The Contribution of Metallic Coils”, also revealed that the amount of metal found in the e-liquids post-heating is far higher than that of regular cigarettes. 

“Metals that are contained in the group resistance wires leach metals such as aluminium, chromium, iron, lead, manganese, nickel, and tin. The aforementioned concentration is far higher compared to traditional cigarettes.”

The study examined 56 e-cigarette devices used daily, with samples collected from the refilling dispenser, aerosols, and remaining e-liquid in the tank. Higher median metal concentrations were found in the aerosol and tank compared to the dispenser.

Arsenic was also detected in dispenser samples, with concentrations similar in aerosol and tank samples.

Aerosol mass concentrations for chromium, magnesium, nickel, and lead exceeded health-based limits in close to 50 per cent or more of the samples, leading researchers to conclude that e-cigarettes pose a potential source of exposure to toxic metals, which can be harmful when inhaled.

These findings lead researchers to conclude that e-cigarettes are a potential source of exposure to toxic metals and to metals that are toxic when inhaled. 

Furthermore, psychoactive substances such as ethanol, caffeine, powdered cocaine, ecstasy, hallucinogens, heroin, methamphetamine, prescription pain medications and prescription stimulants can be added to the e-liquid, said Dr Murallitharan. 

An investigation by CodeBlue uncovered the open sale of narcotics-laced vape liquids on platforms like Facebook, Instagram, Telegram, and Whatsapp. 

While sellers often do not explicitly mention the psychoactive substance, they market their products as containing CBD (cannabidiol), without the marijuana psychoactive component.

Despite stating that the product contains CBD, sellers market their products as being capable of producing a high and place warnings that users are not to vape the e-liquid while driving, and users who are ‘chasing the dragon’ openly leave reviews on the effectiveness of the products. 

EVALI, Nicotine Poisoning And Cigarette Complications Costing Malaysia Millions

The surge in nicotine poisoning, EVALI cases, and smoking-related diseases imposes a significant financial burden on Malaysians and has huge implications on the country’s economy.

Dr Murallitharan said that the cost of treating an EVALI patient exceeds RM150,000 for a 12-day hospital stay, estimating a total cost of RM369 million to treat 2,445 people by the year 2030.

Dr Zaliha is aware of the high cost of treatment, said Dr Murallitharan, attributing his statement to the health minister’s written parliamentary response on June 6.

The health minister, apart from laying down the amounts for the treatment of EVALI, stated that Malaysia, as of June 6, had as many as 18 cases of EVALI and 20 other cases linked to the use of e-cigarettes. 

In her written response, she also emphasised the MOH’s determination to ensure the generational end game (GEG) provision – which seeks to ban conventional and electronic cigarettes for anyone born from 2007 throughout their lifetime – of the Control of Smoking Products for Public Health Bill 2023 is passed. 

Furthermore, the release of secondhand aerosol in the form of vape can expose the public to the numerous toxic micro particles that are contained within the vapour. 

“E-cigarette emissions normally contain nicotine and poisonous substances that endanger the user and others who do not mean to be exposed to the aerosol.”

While the harmful chemicals in e-liquid pose significant health risks to users and increases the amount of the country spends on treatment, the e-cigarette or vape device itself poses a danger to users in the form of spontaneously combusting lithium-ion batteries. 

As the prevalence of e-cigarettes and vape devices grows, countries like the United Kingdom, Australia, and the United States have reported incidents of devastating fires linked to the spontaneous combustion of vape devices, including disposable ones discarded before combustion.

Other combustion cases have left the victims with severe burns, as evidenced by Dr Murallitharan’s case report titled “Burns resulting from spontaneous combustion of electronic cigarettes: a case series” published in the Burns and Trauma Journal in 2016.

The report examines severe burns caused by e-cigarettes spontaneously combusting over a six-month period. Patients with e-cigarettes in their pants pockets during combustion suffered substantial burns, necessitating hospitalisation and surgery.

The report concludes that e-cigarettes are hazardous, capable of causing significant burns, and advocates for raising awareness among consumers and the general public about the life-threatening potential of these devices.

Lacuna Post-Delisting Gives Adolescents Easier Access To Vape 

The lacuna, or legal gap, following the delisting of liquid and gel nicotine has facilitated easy access to vape devices by children and teenagers, according to Dr Murallitharan – who referenced the National Health and Morbidity Survey (2022) which revealed the increase in the number of vapers aged 13 to 17 from 9.8 per cent in the year 2017 to 14.9 per cent in the year 2022. 

Dr Murallitharan, who is also Managing Director of the National Cancer Society Malaysia (NCSM), submitted a news article illustrating how the display of vape devices in grocery and convenience stores and restaurants without control is a form of inducement targeted at young children and adolescents and makes these dangerous and addictive products widely and easily accessible.  

“It was discovered that among the premises, some of them placed vape boxes close to or at the area where sweets and food were sold. There are some that place [vape paraphernalia] too low, lower than three feet from the floor, which is a level that children find easy to see and reach.

“The shape of the vape [device] in the various attractive forms like children’s toys can be found in many food flavours and small sizes that are easy for children to use with cheap prices become the cause of the increase in use among teenage circles [and] children.”

Dr Murallitharan’s submitted evidence included a Kosmo article in Bahasa Malaysia, exposing shopkeepers in Ipoh displaying vape devices next to sweets like Eclipse mints, Sugus, DoubleMint chewing gum, and snacks.

This strategic placement has the potential to attract teenagers and children, luring them into purchasing these devices, as highlighted by the article. 

The National Poison Centre identified such practices as part of the tactics used to entice adolescents into a lifelong addiction.

Vape prices, especially those of the popular disposable and pod vape devices, can be notoriously cheap. A disposable vape can be as cheap as RM15, and adolescents can purchase entire vape “starter kits”: two vape pods (small cartridge-like e-liquid tanks) and a vape pen for as low as RM35

Additionally, Dr Murallitharan argued that adolescents who start vaping have a higher likelihood of moving on to regular cigarettes. 

“Analysis has shown that teenagers that have used e-cigarettes have a higher risk to start smoking compared to teenagers that have not used e-cigarettes. 

“The paragraph from the article titled ‘The effect of e-cigarettes on smoking cessation and cigarette smoking initiation: An evidence-based rapid review and meta-analysis,’ by Ying-Ying Zhang, Fan-Long Bu, Fei Dong, Jian-Hua Wang, Si-Jia Zhu, Xiao-Wen Zhang, Nicola Robinson and Jian-Ping Liu: 

“‘In terms of smoking initiation, adolescents who ever used e-cigarettes had a greater risk for smoking initiation than non-users, the findings were consistent with one included systematic review. No serious adverse events were reported in the included studies.’”

The research covered a five-year period (2015 to 2020) and included systematic reviews, randomised controlled trials (RCTs), and cohort studies. 

The study concluded that there is low certainty evidence suggesting e-cigarettes may be potentially effective for smoking cessation but may also be associated with smoking initiation in adolescents.

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