Making sense of the debate on Singapore’s ban on e-cigarettes
Vaping is becoming increasingly popular, especially in countries that are slow to regulate its use. At the same time, the debate on whether e-cigarettes are harmful or not is more heated than before, including in Singapore where they are completely banned.
Vaping is becoming increasingly popular, especially in countries that are slow to regulate its use.
At the same time, the debate on whether e-cigarettes are harmful or not is more heated than before, including in Singapore where they are completely banned.
In the United States, a recent Centers for Disease Control and Prevention report stated that there were 1.5 million more youth e-cigarette users in 2018 than 2017, adding that “those who were using e-cigarettes were using them more often”.
Popular e-cigarette brand, Juul, saw sales surged almost 800 per cent in one year by mid-2018.
In part, this is due to the company’s marketing efforts to make vaping appear cool, even coining its own verb “Juuling”.
How can we better understand the popularity of e-cigarettes and the continuing debate over whether they are harmful or less harmful than traditional tobacco cigarettes?
The option of e-cigarettes as a harm reduction strategy has divided the tobacco control community.
Opponents express deep reservations about the efficacy and effectiveness of e-cigarettes as reduced-risk products, while proponents believe that they make a viable tobacco end-game option.
This dichotomy was also evident at a recent Public Health Thought Leadership dialogue at the Saw Swee Hock School of Public Health.
Although the topic was on tobacco control measures, the most popular questions and comments surrounded e-cigarettes.
The dialogue veered from “What else can Singapore do to bring down its current stagnated prevalence of smoking?” to “Why can’t Singapore allow the use of e-cigarettes when certain public health authorities have already demonstrated that the benefit outweighs the harm?”
This month, Member of Parliament Melvin Yong too asked in Parliament if the Government will review the ban on e-cigarettes as an alternative for long-term smokers to help them cut down on their smoking habit.
In a written reply, Health Minister Gan Kim Yong reiterated the various reasons for the ban, including the harmful health effects of e-cigarettes and the danger of it becoming an entrenched habit here.
Singapore adopts a harm restriction approach in its tobacco control, including limiting the places where one can smoke, taxation, advertising bans, and more recently, raising the minimum legal age for smoking and introducing standardised packaging of tobacco products.
Some argue that while such measures have successfully halved the high proportion of smokers from the 1950s and 60s, the last decade of stagnation in smoking rates calls for a new approach.
Perhaps the answer lies in harm reduction strategies, a well-accepted and established approach in public health.
The idea of harm reduction for smoking was based on the late psychiatrist Michael Russell’s statement: “People smoke for nicotine but they die from the tar”.
This understanding of nicotine addiction in smokers drove the use of nicotine patches as well as low-tar cigarettes, and more recently, the introduction of e-cigarettes as a smoking cessation aid.
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The variety of e-cigarettes abounds, ranging from heat-not-burn cigarettes to aerosols generated by heating a liquid containing nicotine, propylene glycol, glycerine and flavouring (vaping).
The heating of these chemicals do produce toxic substances and the long-term health effects remain unknown.
The debate on whether vaping is an effective smoking cessation aid or “gateway” for non-smokers to pick up smoking continues.
On one hand, results from well-conducted trials of the efficacy of vaping as an aid to smoking cessation appear encouraging.
Modelling studies done in the West seem to suggest that vaping is a cost-effective way of reducing the number of smokers in their communities. But before we start generalising these conclusions to Singapore, it is important to distinguish “efficacy” studies from “effectiveness” studies, and differentiate the implications of their results.
Efficacy studies tend to focus on the biological effects of the intervention. The positive trial results suggest that nicotine vapour from e-cigarettes exert similar biological responses to nicotine delivered through smoking.
Such biological responses are likely to be the same across different populations. On the other hand, effectiveness studies are different.
They apply the results of efficacy studies to real world situations. Since real world circumstances vary in different communities, we need to perform local and contextualised effectiveness studies.
There is also a need for deeper analysis of efficacy studies on the use of e-cigarettes as smoking cessation aids. A recently published study showed that only 4 per cent of smokers who used e-cigarettes quit completely while the majority continued to use e-cigarettes after quitting smoking.
Of even greater concern is that a large proportion who failed to quit became dual users.
There is increasing evidence of a “gateway” effect when e-cigarettes are used recreationally. Most of the modelling studies do apply a range of potential “gateway” effects to demonstrate the robustness of their models.
However, the more pertinent question is whether to allow e-cigarettes’ growth as a consumer product. It is after all a delivery system for an addictive substance, albeit without the cigarette tar.
Sure, we can argue that all consumer products aim to make addicts out of everyone, be it food and beverages or electronic games, but both policy-makers and society need to decide whether vaping is similar to or worse than sugar-sweetened beverages.
If we do allow e-cigarettes in the future, it is prudent to restrict its use to smokers, possibly as a prescription device.
The vaping industry is of course keen to have e-cigarettes as consumer products rather than prescription devices. Furthermore, the tobacco industry’s involvement in vaping is troubling.
Tobacco giant Philip Morris' parent company Altria Group invested US$12.8 billion to own 35 per cent of Juul Laboratories in December 2018.
It may be a genuine attempt by a key industry player to diversify its product offerings as its foresees the world becoming tobacco-free one day.
Yet, it is also possible that industry players see the potential of a large “gateway” effect and are creating a runway today to bring in tomorrow’s tobacco addicts.
Creatively, they may extend the runway by normalising vaping through offering flavoured zero-nicotine vaping alternatives, which will circumvent all the restrictions on tobacco products.
The tobacco industry has long adopted such tactics for self-preservation. In the 1990s, for instance, it undertook a decade-long project (Project Sunrise) to sow differences within the tobacco control community.
For Singapore, the focus should remain the creation of a tobacco-free nation. Vaping is not the magic bullet.
We need to continue our harm restriction approach, accept effective harm reduction approaches for smokers and explore harm removal options.
ABOUT THE AUTHOR:
Dr Chia Kee Seng is Professor at the Saw Swee Hock School of Public Health, National University of Singapore, and a board member of the Health Promotion Board.