COMMENT: E-cigarettes – Harm reduction, not elimination, should be aim of Singapore's public health policy

A saleswoman exhales vape as she talks to a customer at the Vape Shop that sells e-cigarette products in Beijing, China, on 30 January, 2019. (Reuters file photo)

By Andrew da Roza

In his speech at a recent Health Promotion Board roadshow, Amrin Amin, Senior Parliamentary Secretary for Health and Home Affairs, made it very clear that the Singapore government needs to ensure that the public and the young know the reasons for the ban on electronic cigarettes (e-cigarettes).

The Sembawang GRC Member of Parliament noted, however, that if there is good, sound evidence about using e-cigarettes as a smoking cessation aid, the government is willing to study it.

This is indeed laudable. There is no doubt that excellent public health policy must be based on sound scientific evidence.         

With his remarks in mind, we should look at a number of credible, published, and peer-reviewed scientific studies on e-cigarettes and other related issues that ought to form the basis of public health policy in Singapore – and the public and young need to know about them.

Is smoking harm reduction legitimate?

Harm reduction for cigarette smoking has long been the public health goal in Singapore.

For instance, nicotine replacement therapy products, such as nicotine patches, gums, and lozenges, are readily available over the counter while nicotine inhalers and nasal sprays are legal here.

Encouraging smokers to substitute nicotine from conventional cigarettes for another, safer form of nicotine in alternative products is recommended by the World Health Organization (WHO). This harm reduction strategy is enshrined in the WHO Framework Convention on Tobacco Control 2004, and in the WHO MPOWER measures, which Singapore has adopted.

The regulation and promotion of e-cigarettes is simply another harm reduction strategy through nicotine replacement to counter the global smoking epidemic.  

Logic. e-cigarette products are seen for sale in a shop in Manhattan in New York City, New York, on 6 February, 2019. (REUTERS file photo)

Are e-cigarettes poisonous?

The vapour from e-cigarettes indeed contains chemicals that – with sufficiently high accumulated doses over many years – may cause some degree of health hazard but this is uncertain.

Long-term population studies over 30 or 40 years will establish relative safety but banning e-cigarettes will prevent such studies in Singapore. In any case, the public health issue is not whether e-cigarettes are completely safe.

Coffee, chocolate, sugar, alcohol and other consumer products are not completely safe. The major difference is that these products do not contribute towards preserving health and life, in the way that e-cigarettes do as a possible aid to help smokers quit their use of conventional cigarettes.

The public health issue is whether smokers and secondhand “smokers” who inhale highly toxic tobacco smoke would experience substantial harm reduction from the former group switching to e-cigarettes.

E-cigarettes do not burn tobacco, and thus contain only a fraction of tobacco smoke chemicals. In addition, e-cigarette vapour has much lower doses of these chemicals than cigarette vapour – in some cases 300 per cent to 400 per cent lower.

The credible, published toxicological studies on e-cigarette vapour are therefore of utmost importance to the public. The particulate size in e-cigarette vapour is not the issue – it is more important to know what those particles are and their effects.

These studies are the basis for the generally well-accepted scientific findings that show e-cigarettes are very likely to be 95 per cent safer than conventional cigarettes.

It should be noted that nicotine replacement therapy products have some of the same chemicals and doses as e-cigarettes, such as tobacco-specific nitrosamines, metals, and aldehydes.

Although these studies can be easily accessed online, there is still a tendency to cite other studies that show that e-cigarette use is dangerous.

However, in many cases, there has been a misinterpretation of research findings, poor research methods, or assumptions that are not based on real-world conditions.

For example, a high level of formaldehyde was reportedly found when e-cigarette liquid was over-heated to levels unpalatable to e-cigarette users. But there is no indication to show that e-cigarette users are exposed to dangerous levels of aldehydes.

Another example is that stressed mice poisoned with very high levels of nicotine twice daily for two weeks were more likely to lose weight and die when exposed to bacteria and viruses. But this has no biological relevance for e-cigarette users.

Crucially, unlike tobacco, e-cigarette liquids are artificial so regulations can make them safer – banning them and leaving them to the forces of the black market will not.

E-cigarette devices are placed on a shelf for sale in a store in Prague, Czech Republic, 31 January, 2019. (Reuters file photo)

Are e-cigarettes effective?

Whether e-cigarettes are effective to enable smokers to switch from conventional cigarettes is also the subject of a recent peer-reviewed scientific study.

A study of 886 participants published in The New England Journal of Medicine found that the one-year smoking abstinence rate was 18 per cent for e-cigarette users, compared with 9.9 per cent abstinence in a conventional nicotine replacement therapy group. In other words, e-cigarettes are twice as effective as nicotine replacement therapy in helping smokers to quit their habit.

However, the results of this landmark, randomised controlled trial are likely to have understated the true value of e-cigarettes in aiding smoking cessation.

Nicotine replacement therapy is unpopular with smokers – with only two to four per cent of smokers using it for smoking cessation – for several reasons.

The therapy does not deliver enough nicotine, fast enough to reduce tobacco smoke cravings. It is also not effective as it has none of the sensory cues of smoking – feelings in the lungs and throat, tastes and the sight of vapour – in addition to the use of the hands and fingers, and the rituals and social connections. These are the characteristics of conventional cigarettes and e-cigarettes.

Nicotine replacement therapy products also do not have the visual appeal that e-cigarettes have.  

Finally, smokers are averse to admitting that they are “sick” by visiting a pharmacy for nicotine replacement therapy.

Unsurprisingly, there is evidence to show a marked decrease in smoking in countries where e-cigarettes are regulated not banned. Given that the smoking rate has been hovering around 12 per cent in Singapore for the past 18 years, there should be a significant shift in public health policy to bring the rate lower.

A signboard indicates that visitors are only allowed to use e-cigarette devices is displayed at Vape Studio in Tokyo, Japan, on 29 January, 2019. (Reuters file photo)

Weighing risks and rewards

The public heath question then becomes, does the greater popularity and effectiveness of e-cigarettes compared with nicotine replacement therapy outweigh the possible greater health risks?

In 2017, about 3.3 billion taxed cigarettes were sold in Singapore but as many as hundreds of millions of untaxed cigarettes could also have been sold.

An executive summary of a National Population Health survey indicates that 660,000 Singaporeans smoke daily. But this was likely an underestimation of the number of smokers here.

That is because the survey data gathered was based on self-reporting. As smoking is perceived to be a “shameful” subject, data analysis based on self-reports is therefore flawed.

The data also does not include non-daily smokers and non-Singaporeans, who account for a significant proportion of smokers.

Finally, the data does not factor in the number of people who are exposed to secondhand smoke daily. If two non-smoking family members were exposed to the effects of a smoker’s habit on a daily basis, the survey assessment should cover an additional 1.3 million people.

As such, over 2 million people may be at risk from smoking – or nearly half of Singapore’s population.

When we look at these risks, can we say that banning e-cigarettes is, therefore, an overly cautious approach? Does the enormous risk of smoking to the health of Singaporeans and the economy outweigh the possible (unproven) incremental health risks that e-cigarettes may have compared with nicotine replacement therapy?

Every day, the public health authorities in Singapore assess the risks and benefits of consumer health products, pharmaceuticals, and medical devices. They do not look at the uncertainty of health risks alone.

There are no products that have been banned here because of lack of scientific studies covering a span of thirty or more years – certainly not lifesaving ones.  

Now is the time to get all the facts on the table about e-cigarettes and create a safer public health policy in Singapore.

Andrew da Roza is an addiction psychotherapist with Promises Healthcare; and Chairman of We Care Community Services, a voluntary welfare organisation assisting addicts and their families.

He is a mental health advisor to the NCSS Services Committee; and a member of the Singapore Anti-Narcotics Board Association Rehabilitation and Reintegration sub-Committee.      

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