Vaping: What we know and what we don't

Before April 1 (2023), it was illegal to sell vaping liquids containing nicotine and the police were authorised to raid and seize such products from vape shops. — Photos: Filepic

Smoking cigarettes kills.

The 2019 National Health and Morbidity Survey (NHMS) estimated that 27,200 deaths every year are due to tobacco smoking.

The proportion of current smokers attempting to quit their habit was 52.3% in 2015 and 48.9% in 2019.

Meanwhile, the exposure to secondhand cigarette smoke at non-air-conditioned eateries was high at 48.1%.

Smoking-related diseases contribute significantly to years of life lost by the Malaysian population, according to a local study published in May 2022 in the journal Tobacco Induced Diseases.

The Health Minister stated last year that the estimated cost of treating smoking-related diseases will increase from RM2.9 billion in 2007 to MYR8.77bil by 2030.

There has been much public discussion about vaping and its management.

This column seeks to address what is known and what is unknown.

What they are

Electronic cigarettes, also known as ecigarettes or vapes, have been around for about a decade.

A liquid is heated in an ecigarette to produce a vapour that can be inhaled.

They usually contain nicotine – the addictive drug in cigarettes, cigars and other tobacco products.

Users inhale the vapour into their lungs.

Anyone near a user can also inhale the vapour when the user exhales into the air.

Some ecigarettes appear like cigarettes, cigars or pipes.

Others appear like pens, USB drives and other daily items.

Ecigarettes do not contain tobacco, which is the cause of cancer, chronic respiratory conditions, heart disease, stroke, blood circulation problems, diabetes, infections, infertility, osteoporosis, menopause, hearing and/or vision loss, and dental problems.

The bad

It is difficult for consumers to know what the contents of ecigarettes are.

The long-term effects of ecigarettes are still not completely known.

However, we currently know that:

• Most ecigarettes contain nicotine, which is addictive, harmful to a pregnant woman, toxic to a foetus, and can harm the development of an adolescent brain until their mid-20s.
• Ecigarettes can, and do, contain harmful and potentially harmful substances.

  Apart from nicotine, these substances include volatile organic compounds, heavy metals like nickel and lead, cancer-causing substances (carcinogens), and flavourings like diacetyl, a substance associated with serious lung disease.

• Ecigarettes have caused unintended injuries.

  Defective batteries have caused fires and explosions, which have caused serious consequences in some instances.

  Acute nicotine poisoning is toxic with reports of adults and children poisoned by breathing or swallowing ecigarette liquid.

The good

Ecigarettes have been touted as a viable smoking cessation tool.

There are many studies on this that have been inconclusive.

However, in a September 2022 evidence update on vaping in England, commissioned by the UK Office for Health Improvement and Disparities, the authors concluded that “... vaping poses only a small fraction of the risk of smoking and is at least 95% less harmful than smoking (that is, smoking is at least 20 times more harmful to users than vaping)... summarising the relative risks of vaping versus smoking across a range of different products and behaviours, and assessed across multiple biomarkers, can be simplistic and misinterpreted... this does not mean vaping is risk-free, particularly for people who have never smoked.”

The UK government announced on April 11 (2023), a world-first national scheme to encourage one million smokers to swap cigarettes in a “swap to stop” scheme designed to improve their national health and cut smoking rates.

About one in five smokers in England will be provided a vape starter kit, together with behavioural support, to help them quit the smoking habit to achieve the UK government’s ambition to reduce smoking rates to 5% or less by 2030.

But then again

There is consistent evidence from various reviews and cohort studies that vaping products are implicated in smoking initiation.

Ecigarettes contain a certain number of harmful substances, although not as many as in a regular cigarette, and many of them also have nicotine, which is highly addictive.

A meta-analysis by the Health Research Board of Ireland in 2020 reported that the association between ecigarette use and tobacco smoking initiation was four-fold.

The European Commission on Health concluded in 2020 that there was strong evidence of ecigarette use leading to tobacco smoking initiation.

A study, published in December 2020 in the journal Pediatrics, found that regardless of the intentions of youths (in the United States), those that used ecigarettes were 4.6 times more likely to use cigarettes and become tobacco smokers one year later.

Another study, published in May 2020 in the American Journal of Preventive Medicine, reported that American youths who were current ecigarette users were five times more likely that non-current users to become tobacco cigarette users.

Tobacco smoking is very probably more harmful than ecigarettes with more negative health consequences, simply because of the difference in the number of chemicals inhaled from each product.

This has been reported as 41 chemicals in ecigarettes and 7,000 chemicals in tobacco cigarettes.

However, vaping has not been harmless.

There have been reports of hospitalisation due to Ecigarette or Vaping Use-Associated Lung Injury (EVALI), an increase in heart attacks in middle-aged males, and links with pneumonia, pneumonitis and alveolar damage.

Legally available to all

The media reported on April 1 (2023) that through the gazettement of the Federal Government Gazette Excise Duties (Amendment) Order 2023, an excise tax of 40 sen per millilitre will be imposed on ecigarette liquids or gels containing nicotine.

Liquid nicotine was removed from the Poisons List of the Poisons Act on March 31 to ostensibly allow for implementation of the excise tax.

The reason given for this gross error was pathetic and raises many questions, including the failure to distinguish excise duties from the Poisons Act, which is to “regulate the import, possession, manufacture, compounding, storage, transportation, sale and use of Poisons”.

Since April 1 (2023), ecigarettes containing nicotine could be sold legally to anyone, including children.

Malaysia’s tobacco control policy targets a smoking prevalence of 15% of the population by 2025, and less than 5% by 2045.

Malaysia’s smoking prevalence was 21.3% in 2019, compared to 22.8% in 2015, a paltry decline of 1.5%.

With the removal of nicotine from the Poisons List and the current situation in which ecigarette use is unregulated, it is very probable that Malaysia will not achieve the targets in its tobacco control policy.

The Health Ministry has effectively shot itself in the foot.

When used correctly...

Ecigarettes have the potential to benefit non-pregnant adult smokers if used as a complete substitute for cigarettes and other tobacco products.

Ecigarettes are not safe for teenagers, young adults and pregnant women, and adults who do not currently use tobacco products.

While ecigarettes have the potential to benefit some people and harm others, there are still significant knowledge gaps about this product.

Additional research can help us understand the long-term health effects of ecigarettes.

Readers who have never smoked or used other tobacco products or ecigarettes, are advised not to start.

It is still not too late for liquid nicotine to be restored to the Poisons List – it’s better to be safe than sorry.

Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email [e-mail]. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only, and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.