by Dr. Helmy Haja Mydin. First published in the News Straits Times 9 May 2014

LAST week, the United States’ Food and Drug Administration (FDA) announced regulations on the use of electronic cigarettes (e-cigarettes) and tobacco products such as cigars, shisha and pipes.

If recommendations are finalised after a 75-day public consultation period, measures such as setting the sales age limit to 18, placement of health warnings on the product and prevention of sales using vending machines will be put into place.

These measures were long awaited and have been of particular interest to consumers and manufacturers of e-cigarettes, a product that is rapidly gaining popularity.

What are e-cigarettes? They are battery-operated devices that are usually sold in the shape of cigarettes or pipes. These devices come with a replaceable cartridge containing liquid nicotine. The nicotine is heated up by the battery to produce vapour that allows users to inhale a nicotine “hit”.

E-cigarettes first gained popularity in China in the early 21st century. Initial sales were plagued by unreliability but the industry has grown from global sales of US$20 million in 2008 to US$3 billion last year, according to Canaccord Genuity, a financial services group.

Wells Fargo, the American investment bank, has predicted that revenues from e-cigarettes could overtake tobacco sales in the US in less than a decade.

This has attracted the attention of Big Tobacco — e-cigarettes are both a threat to their lucrative revenue stream and an opportunity to diversify. It is not, therefore, not surprising that all the big four (RJ Reynolds, Philip Morris International, Japan Tobacco International and Imperial Tobacco) are either developing or already selling e-cigarettes.

In the United Kingdom, the use of e-cigarettes grew exponentially when the British government passed legislation banning smoking in enclosed public places.

E-cigarettes allowed users to “vape” (the term used to describe inhalation of e-cigarette vapour) indoors, and thus remove both the inconvenience of having to go outside for a cigarette break and the stigma attached to it. Users were also increasingly attracted to the perceived health benefits of switching from tobacco smoking to vaping.

It is difficult to overstate the negative impact of tobacco smoking. Based on current trends, the World Health Organisation (WHO) anticipates that one billion premature deaths will occur this century.

Millions of cases of cancer, heart diseases and respiratory ailments are directly linked to tobacco smoking. Worryingly, the World Bank estimated that up to 50 per cent of adult males in Malaysia were smokers in 2009, a number that is likely to have increased.

Enter e-cigarettes. Last year, Goldman Sachs identified e-cigarettes as one of eight disruptive forces (alongside 3D printing and big data) that will alter the landscape for traditional industries.

One of the major selling points of e-cigarettes is that they do not contain tobacco or many of the lethal toxins that are associated with cigarette smoking. Proponents are convinced that with proper regulation, e-cigarettes could play a major role in risk-reduction — reducing the number of people who suffer and die from tobacco-related disease.

As a consequence, e-cigarettes are billed as an ideal replacement tool for tobacco-smoking. In this scenario, there is the public health benefit of moving millions of smokers from the more lethal form of tobacco smoking to the inhalation of a product that does not contain tobacco but provides a similar level of user satisfaction.

It has also been promoted as an aid for smoking cessation, in a similar manner to nicotine replacement patches. Anecdotal evidence also suggests that it may help prevent tobacco smoking recidivism, which remains unacceptably high despite decades of effort.

One of the main criticisms about e-cigarettes is the lack of information regarding contents — the dangers of inhaling unknown chemicals does not really need to be elaborated upon. It can also be easily purchased on the Internet, where there is very little scope for regulation.

This lack of transparency allows unscrupulous sales that the FDA is seeking to circumvent by not only requiring manufacturers to register their products and ingredients, but by only allowing marketing of the products after FDA review.
Another criticism is the physical danger posed by both the electronic and chemical components. Consumers have complained of over-heating. Incidences of poisoning have also been reported.
Even more worryingly, there appears to be significant harm to youth. A recent report by the United States’ Center for Disease Control and Prevention (CDC) stated that up to 51 per cent of calls to poison control centres involve children. These include cases of burns and nicotine toxicity.

The risk to children and the young also extend to the perception held by some public health experts that e-cigarettes will lead to the “normalising” of tobacco smoking, thus reversing decades of gains in the war against tobacco smoking.
Corporate Accountability International, an American non-governmental organisation which organises public health campaigns, has gone so far as to accuse the industry of glamourising cigarettes. The concerns are not baseless — during a recent trip to Europe, I was appalled at advertisements of flavoured e-cigarettes that were targeted at teenagers.

More objectively, the CDC reported that the fraction of high school students who have used e-cigarettes more than doubled in one year, from 4.7 per cent in 2011 to 10 per cent in 2012. What is unclear though is if these students used e-cigarettes instead of tobacco or if there was indeed a slippery slope between starting e-cigarettes and “progressing” to tobacco smoking.

Professor Martin McKee, an expert on public health at the London School of Hygiene and Tropical Medicine, is even more critical: he is of the opinion that e-cigarettes provide tobacco groups with a way to buy credibility and access to politicians.

He was quoted by the Financial Times as saying: “This is not a respectable industry, and the WHO Framework Convention on Tobacco Control is very clear that governments should not be having discussions with the tobacco industry.”

In my opinion, it is premature to ban or even overly regulate e-cigarettes. Such moves will only serve to prevent upstarts from penetrating a market that is heavily dominated by the big four companies. An opportunity to shift consumers away from tobacco smoking is one that is too great to ignore.

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Dr. Helmy Haja Mydin is an associate of IDEAS

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