NOVEMBER 12 — Perhaps the hottest debated topic for the past two weeks in Malaysia would be shall we ban or regulate the sales of e-cigarette or vapour? The debate about e-cigarette has divided not only the members of the general public, even among the public health community, opinions were diverse; while various groups with relevant interests putting up with their own perspectives and interpretations.

Whilst most agree on the need for further scientific study to confirm the products’ unproven safety claims, some tobacco control advocates see e-cigarettes as a convenient gateway to tobacco abuse and subsequently nicotine addiction, in particularly vulnerable groups, e.g. students and young people; hence fully supported their removal from the market. Others view them as far less harmful alternatives to the combustible traditional cigarettes, which include more than 60 known carcinogens and other poisons as well as the top leading cause of preventable disease in most develop and developing countries.

The story is far from over where countries such as Australia, Canada, Brazil, Mexico, Hong Kong and our neighbour, Singapore have decided to ban their sales altogether.

E-cigarette: Vaping the tobacco world by storm

The very first electronic cigarette was envisaged by Herbert A Gilbert in 1962 and was described in its patent as “... a smokeless non-tobacco cigarette ... to provide a safe and harmless means for and method of smoking by replacing burning tobacco and paper with heated, moist, flavoured air...”

However, due to limitations in technology and because tobacco was not widely recognised as harmful at the time, the device never reached mass production.

Forty-one years later in 2003, a pharmacist in China, Hon Lik invented the modern electronic cigarette and was introduced to the huge Chinese market the following year. The company he worked for, Golden Dragon Holdings, changed its name to Ruyan (meaning “resembling smoking”), and started exporting its products in 2005–2006, before receiving the first international patent in 2007.

In 2013, Imperial Tobacco acquired the intellectual property of e-cigarette owned by Hon Lik for US$75 million (RM327 million).

The key theme behind e-cigarette design is to make it very similar to a real cigarette which makes using e-cigarettes a much easier transition for traditional heavy smokers who suffers the full adverse impact of tobacco cigarette. It was designed as a less harmful alternative to tobacco smoking.

The most common e-cigarette ingredients are nicotine, propylene glycol, glycerine, flavouring and water. This compares to more than thousands dangerous chemicals involved in smoking cigarettes including carbon monoxide, polonium, formaldehyde, cadmium and ammonium to name a few, may sound much harmless to the tobacco smoking public who find it challenging to attain smoking cessation, even though are bearing the brunt of adverse impact on their health.

A case of better the devils you know than you don’t know?

As a consequence of previous lessons learned from “Big Tobacco” companies, the public health community is usually suspicious and sceptical of e-cigarettes and has routinely advised against their use.

The public health community would advise on the side of caution, indicating that very little scientific evidence is available to show, one way or the other, that e-cigarettes are safe to use, or that they help in the smoking cessation process. In addition, many physicians believe that patients who vape are merely substituting one form of nicotine addiction for another.

The harmful effects of smoking on human health are obvious and well documented. In contrast, effects of vaping on human health are inconclusive due to the extreme paucity of empirical research investigating the presence of vaping-induced health hazards and/or benefits.

Hence, in 2013, Professor Robert West from University College London and his team was tasked to provide a regular update on E-cigarettes to the UK All-Party Parliamentary Group with the most recent version (4th) presented on 1st July 2015 stated that:

“Safety: E-cigarettes are much less harmful than smoking but not 100 per cent safe, further elaborated that; from the concentrations of potentially harmful inhalants in vapour, e-cigarette use from brands that have been tested so far would be expected much less harmful to health than smoking tobacco cigarettes. Well publicised reports of potential harmfulness of e-cigarette vapour have typically not compared this with tobacco cigarettes and/or have set up conditions that rarely occur in practice, e.g. the precise extent of harm from long-term use is not known but has been estimated at around 1/20th that of smoking tobacco cigarettes.”

E-cigarette — is there such things as a free puff?

Perhaps the greatest concern of the health authority and public health community is that availability of e-cigarettes will entice a whole new generations of teens and young adults toward vaping, which could ultimately lead to smoking conventional cigarettes.

This was demonstrated in a survey conducted by the US Centre of Disease Control and Prevention in their 2014 National Youth Tobacco Survey. The findings show that current e-cigarette use among high school students increased from 4.5 per cent in 2013 to 13.4 percent in 2014, rising from approximately 660,000 to two million students.

More alarmingly, among middle school students, current e-cigarette use more than tripled from 1.1 per cent in 2013 to 3.9 per cent in 2014—an increase from approximately 120,000 to 450,000 students.

This is the first time since the survey started collecting data on e-cigarettes in 2011 that current e-cigarette use has surpassed current use of every other tobacco product overall, including conventional cigarettes.

Understandably, the public health community is concerned that increased acceptability of e-cigarettes could increase worldwide nicotine dependence, especially among the young as they are enticed by the various flavour options e-cigarettes and the vapour devices as electronic gadgets, becoming a trend itself.

“We want parents to know that nicotine is dangerous for kids at any age, whether it’s an e-cigarette, hookah, cigarette or cigar,” said CDC Director Tom Frieden, MD, MPH. “Adolescence is a critical time for brain development. Nicotine exposure at a young age may cause lasting harm to brain development, promote addiction, and lead to sustained tobacco use.”

The fear that traditional smokers will substitute vaping for smoking in settings where smoking is not permitted without any real intention of quitting conventional cigarettes is real too.

E-cigarette — where do we go from here?

When compared to the harmful effects of smoking, studies suggest that vaping could be used as a possible “harm reduction” tool. There is evidence supporting e-cigarettes as an aide for smoking cessation, at least as comparable to currently available Nicotine Replacement Therapies.

Less evidence exists to suggest that e-cigarettes are effective in recovery or achieving abstinent from nicotine dependency. E-cigarettes are fast becoming a new “tobacco” industry that could reduce the incidence of more harmful traditional smoking.

Hence, the aimed of this article and also that the public health agency may consider is finding a middle path towards optimising human health and safety at present as well as minimizing the potential ill effects e-cigarettes may have on the public in future.

Regulations are needed to limit the adoptions of E-cigarettes by non-smokers such as:

  • Require that e-cigarette components be sold in child-resistant packaging that clearly and accurately indicates nicotine concentration and appropriate safety warnings.
  • Prohibit manufacturers from making unproven health claims.
  • Prohibit sale to persons under 18 years of age.
  • Prohibit use in federally regulated public spaces.
  • Restrict advertising and promotional activities for these products.
  • Prohibit use of flavourings in e-liquids that are specifically designed to appeal to youth.

For current smokers, regulations are needed to:

  • Address both e-cigarettes that do and do not contain nicotine.
  • Require that e-cigarettes be visually distinct from tobacco products.
  • Establish a maximum level of nicotine.
  • Establish safety standards of all of the components and also require manufacturers and importers to disclose information regarding ingredients.

In addition, current smokers should be encouraged to quit using a brief intervention strategy such as the 3A’s technique: Ask, Advise and Act. If they enquire about or are currently using an e-cigarette, the pros and cons need to be explained, and ultimately, they need to make the decision based on the best evidence available. E-cigarettes should ideally be used as a smoking cessation aid, with ultimate cessation of all tobacco related products.

To summarise, e-cigarettes have many positive features (as compared to traditional tobacco) and a few potentially concerning features but as of yet, few, if any, ugly ones. We should encourage a rational, yet cautious approach to e-cigarettes, which could be a game changer in the fight against tobacco.

We should push for further reduction in youth tobacco use through the regulation of the manufacturing, distribution, and marketing of all tobacco products coupled with proven strategies. These strategies may include funding effective smoking cessation programmes, increasing prices of tobacco products, implementing and enforcing comprehensive smoke-free laws, and sustaining hard-hitting media campaigns.

* Ko Teik Yen is a clinical hypnotherapist practicing at one of the private hospital in Kuala Lumpur. One of his key interest is in helping people with impulsive control behaviours and in smoking cessation with integrated quit smoking programmes.

** This is the personal opinion of the writer or publication and does not necessarily represent the views of Malay Mail Online.