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Is Singapore’s ban on e-cigarettes misguided?

One reason for Singapore’s ban is that the authorities are choosing to take a moral stand: that allowing e-cigarettes and heat-not-burn tobacco products can be seen as condoning nicotine addiction and addiction is sufficiently heinous to outweigh the benefits of reduced smoking. But there is another, equally valid, but conflicting moral stand. Banning these devices prevents smokers from improving their health (and the health of loved ones) and extending their lives.

A 15-year-old boy vapes in New York. The New York Times file photo

A 15-year-old boy vapes in New York. The New York Times file photo

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A series of foreign government reports in recent months on how e-cigarettes and heat-not-burn tobacco products can help curb smoking has put the spotlight on Singapore’s ban on these products that kicked in on Feb 1.

Days after the ban, Public Health England (PHE, an executive agency of the United Kingdom Department of Health and Social Care) published its review of the current scientific evidence on e-cigarettes and heat-not-burn tobacco products. The latter device heats a specially prepared tobacco stick to a high enough temperature to create a vapour but not smoke, unlike e-cigarettes, which vaporise man-made liquids containing nicotine, the highly addictive compound in tobacco smoke.

PHE concluded that e-cigarettes pose only 5 per cent or less of the risks of smoking, and switching completely from smoking to vaping “provides substantial health benefits”.

Heat-not-burn products may be considerably less harmful than tobacco cigarettes, PHE also noted. Furthermore, e-cigarettes are likely to expose users and bystanders to lower levels of particulate matter and toxins.

PHE believes that e-cigarettes have helped 20,000 or more successful UK residents quit smoking each year; and e-cigarette use is associated with improved quit success rates and an accelerated drop in smoking in the UK. PHE also found that some academic studies that have reported contrary findings are misleading.

PHE’s evidence review came just a few weeks after a January 23 report by the United States National Academies of Sciences, Engineering and Medicine on e-cigarettes that was commissioned by the US Food and Drug Administration. The report concluded that, based on the available evidence, “e-cigarettes are likely to be far less harmful than combustible tobacco cigarettes”. Completely substituting e-cigarettes for cigarettes reduces users’ exposure to numerous toxicants and carcinogens and improves health; the report added. Vaping can help people quit smoking; and that there are no known long-term health effects of vaping, it said.

Also in February, the American Cancer Society issued a position statement which recommended that clinicians support smoker’s attempts to use less harmful substitutes, and switching to e-cigarettes is preferable to continuing to smoke.

If science shows that e-cigarettes and heat-not-burn tobacco products reduce smoking, why did Singapore ban e-cigarette use, ownership and possession on Feb 1? Singapore’s health policy is in sharp contrast to health policies in the UK, Europe, New Zealand, Canada, the US, South Korea and Japan – which have all seen declines in smoking by allowing e-cigarettes and heat-not-burn tobacco products.

The Ministry of Health in Singapore has maintained that there are no long-term (25 to 30 year) scientific studies to show whether these devices materially increase or decrease diseases in the using population. Thus, caution should be taken in acting on the current evidence. However, no other public health policy requires a new technology that could potentially save lives and prevent disease be tested for 25 to 30 years before it can be used.

One reason for Singapore’s ban is that the authorities are choosing to take a moral stand: that allowing e-cigarettes and heat-not-burn tobacco products can be seen as condoning nicotine addiction and addiction is sufficiently heinous to outweigh the benefits of reduced smoking.

But there is another, equally valid, but conflicting moral stand. Banning these devices prevents smokers from improving their health (and the health of loved ones) and extending their lives.

Of course, e-cigarettes, heat-not-burn tobacco products, nicotine replacement therapies, Varenicline and bupropion are not 100 per cent safe – but they are safer than cigarettes.

To be sure, Singapore is not the only country contemplating or imposing e-cigarette bans.

Thailand has banned e-cigarettes since 2014, because it believes that these devices lure young people into smoking though they are reports suggesting Thailand may be re-considering the ban. In the Philippines, which is also considering a ban, the Department of Health has said that there is insufficient evidence of the safety of e-cigarettes, and that big tobacco firms may be using them to re-normalise smoking.

In contrast, some analysts believe that Indonesia is contemplating a ban to protect the tobacco market. However, the Philippines may be leaving the door open to treating e-cigarettes as medical devices and regulating them accordingly.

Much is made of these devices being a “gateway” to daily long-term smoking in adolescents – who would not have otherwise been daily smokers. PHE found that the evidence does not support this. UK youth smoking rate is declining and e-cigarette users were virtually all smokers. Similar evidence from the US, shows virtually linear associations between increases in e-cigarette use and declining smoking rates among adolescents.

Common sense also tells us that adolescents who try e-cigarettes are also likely to try many other things, including alcohol, cigarettes and drugs. Which one they start with and which one follows, is not determined by the substance or the device, because this is a function of their vulnerability to using any psychoactive substance. So, with or without e-cigarettes, they are vulnerable to smoking, drinking and using other substances. Thus, the numerous scientific studies that purport to establish that e-cigarettes are the cause of smoking, do little more than to show an association between users and smoker – which is what we would expect, given that individual vulnerabilities are the cause.

It is of course possible that a few adolescent users of these devices take up daily smoking, and continue for years – but does this risk outweighed improving the health of nearly a million Singaporean adult smokers? Public health policy has to weigh up the health of many compared to the welfare of a few.

The health damage from cigarettes only appears when people reach middle age and older. With an ageing population and health costs now exceeding education costs in Singapore, it is critical that the country effectively curb smoking and its associated health costs.

If a questionable moral stand, misinterpretations of the scientific evidence, conflicting interpretations of tobacco companies’ motivations, and a mismatch between the welfare of many and the welfare of a few, are at the root of Singapore’s ban, is it then time to rethink the health policy?

If there are health risks to these devices, a prudent approach is not to ban them but to regulate them, and reduce the risks. To ensure that e-cigarettes and heat-not-burn devices remain 95 per cent safer than cigarettes and to reduce the residual risks (such as the risks presented in the recent US Food and Administration report), a prudent approach is to promote R&D.

These devices can be improved, lowering toxins but increasing the efficiency of nicotine delivery. Regulations can be used to ensure that the heat sticks and devices are of good quality and are safer to use.

Banning may push poor devices into the back market and make them harder for the Government to control. This may well prove a more risky approach.

ABOUT THE AUTHOR:

Andrew da Roza is a psychotherapist and member of several expert committees dealing with addiction, including the Singapore Anti-Narcotics Association.

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