E-cigarettes: Regulation rather than outright prohibition?

e-cigarette-vaping

by Faraaz Amzar. 

How do they work?

Electronic-smoking devices have been around for about a decade, but have recently become popular, particularly in Europe and the United States. These devices consist of a rechargeable battery, a vaporization chamber and a cartridge. An atomizer in the vaporization chamber superheats the e-liquid (which may or may not contain nicotine) and produces a “vapor” – a misty cloud-like smoke, which the user ingests and exhales as he would with a cigarette. The e-liquid contains varying levels of nicotine and propylene glycol, though there have been cases where e-liquids have been found to contain more toxic substances.

 

Government’s position on electronic-smoking devices

The Government has taken a strict stand against the proliferation of such devices. E-cigarettes are banned under the Tobacco (Control of Advertisements and Sale) Act and the Health Promotion Board has warned of the risks of electronic-cigarette smoking [1]. No comprehensive local studies have yet been performed with one local expert commenting that, “much more research is needed” before it can be established whether electronic-cigarette use is a safer alternative to smoking.

Presumably, this prohibition against electronic-cigarettes is part of the slew of other anti-tobacco initiatives recently adopted, including the ban against shisha and display of tobacco products. While the Government’s recent moves towards curbing smoking (particularly among the young) must be lauded, it is unclear whether a complete ban against e-cigarettes is necessary, especially since there is some scientific evidence[2] suggesting that e-cigarettes are safer than traditional cigarettes – a product that remains legal.

 

Legal status of electronic-smoking devices around the world

The legal status of electronic-smoking devices is unclear in many parts of the world. While they are banned in Brazil, Indonesia, Argentina, and some other countries, they remain legal in the United States, the United Kingdom, Australia, and most of Europe. In fact, it appears that no major developed country has completely banned the use of such devices. In some countries, for instance – the United Kingdom, civil society and medical groups have actively promoted the use of electronic-cigarettes as a safer alternative to traditional cigarettes. A recent evidence review published by Public Health England concluded that electronic-cigarettes are “significantly less harmful to health than tobacco”.

 

Is electronic-cigarette use safer than smoking?

Some studies have found that smoking rates have fallen in response to increased electronic-cigarette usage, although others state that no firm conclusions may yet be drawn [3]. The Health Promotion Board thus far has advocated an “abstinence-only” policy against tobacco smoking, stating “there are no safer alternatives to cigarettes when it comes to tobacco products”[4] (in the process, it erroneously classifies electronic-cigarettes as tobacco products). Electronic-cigarettes technically do not contain tobacco (see WHO report 2016).

While the causal link between electronic-cigarette use and smoking cessation is still unclear, the relative risks of electronic-cigarette usage vis-à-vis traditional smoking have enjoyed greater scrutiny. The HPB’s approach ignores some more recent studies, which suggest that electronic-cigarette smoking may be a safer alternative to traditional smoking. The Royal College of Physicians and Public Health England have estimated that electronic-cigarettes are “around 95% safer than smoking”.

even the WHO report does not call for a complete prohibition on electronic-smoking devices but only for additional restrictions on their use.

Of course, the Government’s position mirrors the existing WHO position that countries should curb the use of electronic-cigarettes because of insufficient evidence to show people that they help people stop smoking (You can read the full WHO report here). However, even the WHO report does not call for a complete prohibition on electronic-smoking devices but only for additional restrictions on their use.

The report also recognises that the “number and level of known toxicants generated by the typical use of unadulterated ENDS (electronic nicotine delivery systems) is on average lower or much lower than in cigarette smoke”. The problem is that the levels of toxicants depend on the e-liquid ingredients which are being used. The answer to this problem may lie in the regulation of e-liquids to ensure the use of safer ingredients.

Some experts also argue that electronic-smoking devices are superior smoking cessation devices because they address both the biochemical and behavioral aspects of smoking. The conventional cessation aids like gums, lozenges, inhalers, nasal sprays and nicotine skin patches may not provide the “oral fixation” and “experience of inhaling” that smoking does, which is part of the behavioral aspect of smoking addiction.

 

Prohibition or regulation?

One solution could be to introduce a two-tiered system. This means electronic cigarette delivery systems carrying zero-nicotine or low-nicotine content e-liquids are legalised while those carrying nicotine remain illegal. This would put our policy closer to Australia – a country whose anti-tobacco policies have led to its smoking rates halving in 20 years. Electronic-cigarettes are legal in Australia but those containing nicotine are banned.

To be fair, the government’s fear that electronic-cigarettes are a ‘gateway’ to regular smoking is a reasonable concern. This claim has been both proven and disputed [5] by studies. Of course, no society wants its young to pick up smoking; but this legitimate concern should also be balanced against the possibility of redeeming the many existing smokers who may benefit through the use of such devices.

electronic-cigarettes have the potential to reduce smoking rates in Singapore

The purpose of this article is not to convince people to switch from smoking traditional cigarettes to electronic-cigarettes (which remain illegal), but to argue that electronic-cigarettes have the potential to reduce smoking rates in Singapore. The answer to the electronic-cigarettes conundrum may therefore lie in regulation, not outright prohibition.

Electronic-smoking devices are of course small and easily concealable, with anecdotal evidence suggesting that a large community of “vapers” exists in Singapore. Unregulated e-liquids with unknown (and dangerous) levels of nicotine will continue to be used by some, while others may benefit from safer (albeit illegal) electronic-smoking products as a tool to quit traditional smoking.

Outright prohibition is resource-intensive, entailing substantial enforcement costs; more importantly however, it may not necessarily curb all of the harms associated with electronic-smoking. As more studies are conducted and new evidence sheds light on the relative risks of electronic-smoking, the Government should be willing to reconsider its position on such devices. An inflexible position helps no one, and may even compromise the Government’s push to lower smoking rates over the long-term.

 

Conclusion

The real problem faced by policymakers at the moment is that the jury is still out, meaning that there is still insufficient evidence to enact concrete policy. By entirely prohibiting electronic-cigarettes, this potentially slows down the number of people switching away from traditional cigarettes to safer alternatives. On the other hand, complete deregulation and legalisation may lead to a new generation addicted to nicotine. The Government may still struggle with this quandary for some time; nevertheless, it should not approach the issue dogmatically but remain open to new developments.

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NOTES

[1] https://www.healthhub.sg/live-healthy/29/facts_tobacco_products

[2] McNeill, A., et al. “E-cigarettes: an evidence update.” Public Health England 3 (2015).

[3] Chapman, Simon. “The future of electronic cigarette growth depends on youth uptake.” Med J Aust 202.9 (2015): 467-468.

[4] https://www.healthhub.sg/live-healthy/29/facts_tobacco_products

[5] Lynn T. Kozlowski, Kenneth E. Warner. Adolescents and e-cigarettes: Objects of concern may appear larger than they areDrug and Alcohol Dependence, 2017; DOI: 10.1016/j.drugalcdep.2017.01.001

 

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