THERE is a perception that vaping is a safer alternative to tobacco smoking, but the reality is that we don’t have as much data as we have with cigarettes. What we do know is that vaping is not completely safe and carries with it various health risks.

Until we have sufficient, transparent and independent longer-term data that compares vaping, tobacco smoking and people who do neither, then it’s best to treat vaping and e-cigarettes as no less harmful than cigarette smoking.

We only have relatively shorter-term data that indicates lesser health risks from vaping compared to cigarettes, but even these can be questionable and are confined to relatively limited measurements such as nicotine addiction.

As widely known, there are many more health risks associated with tobacco negatively affecting the heart, lungs, blood vessels, fertility, and many other organs. Furthermore, there are not enough apples-to-apples data to compare cancer risk, which is usually seen as a longer-term impact.

Thus, the principle is to be on the safe side, until we know more about its longer-term implications.

Even then, the shorter-term outlook is quite worrying.

Although some studies may indicate vaping as not a gateway to smoking, there are also studies pointing to an increase in smoking among youth through the use of e-cigarettes.

Similarly, although many experts warn that this opens up the route to smoking, some studies indicate an inverse relationship between vaping and smoking. For example, Levy DT et.al., (2019) presented a reduction in smoking initiation during the period of rise in vaping, resulting in an insignificant net impact at the population level.

As reported by public health portal CodeBlue, the president of IKRAM Health Malaysia, Dr Mohd Afiq Mohd Nor also pointed to the reliability issues of some of these reports, where he mentioned 76 studies as being inconsistent and contradictory.

Dr Mohd Afid also reportedly referenced the 2015 Systematic Review of Health Effects of Electronic Cigarettes by the World Health Organization (WHO) which revealed that e-cigarette manufacturers were funding and supporting most of the studies with conflicts of interest.

With an insufficient number of long-term, reliable, independent and robust data, it is unwise to treat vaping and e-cigarettes as a less harmful option for what could be a mere short-term gain in taxes. This is assuming that taxes can be collected efficiently and shorter-term health implications have not been underestimated.

Getting these two factors wrong could spell a health disaster and severe financial burden for Malaysia.
This is why various quarters are calling out on the controversial (unilateral) decision to exempt nicotine from the Poisons Lists under the Poisons Act 1952, which went against a unanimous objection from the Poisons Board.

Even for cancer risk, which is usually seen as a longer-term risk, it is known that vaping liquid includes thousands of chemicals, some of which are known carcinogenic compounds such as formaldehyde, benzene and metals.

Given Malaysia’s financial situation, the controversial move could be driven by the government’s need to collect more taxes instead of discouraging vaping. Time will tell whether the impact on consumption from increased sales prices is significant.

In any case, both of these reasonings may end up being severely flawed.

Firstly, as reported by CodeBlue, the sin tax rate on cigarettes or vape needs to be at least 75% or higher to effectively discourage non-smokers from initiating and assist existing smokers to quit, as mentioned by Prof Dr Syed Mohamed Aljunid, who is a professor of economics, health policy and management at International Medical University (IMU).

Secondly, Dr Syed Mohamed also pointed out that the sin tax may not be enough to cover the costs of related illnesses.

The government may be “gambling” for a shorter-term gain in tax-based revenues, probably (and mistakenly) hedging against a future of lower health implications compared to smoking. How long before they reap what they sow is anyone’s guess but there is mounting evidence indicating that it may not be that far ahead in the future.

Tobacco needed a few decades before scientific evidence triumphed over the tobacco industry lobby. In the early 1900s, tobacco was deemed trendy and harmless. Then people started to become more aware of the increasing cases of lung disease and cancer in the 1940s and experiments in the 1950s proved the link between chemicals in tobacco and cancer.

By the 1960s society’s perception of cigarettes had changed for the better, with the US Congress leading the way in mandating warning labels on cigarette packaging in 1969.

That’s over six decades of studies looking into over 7000 chemicals involved in cigarette smoke.

Vaping hasn’t had the chance to go through these phases and it should not take as long. Unlike the 1900s, we are in an era of higher awareness of health, scientific progress, health standards and more advanced investigative techniques.

But, at the same time, the magnitude of industry lobby can be said to be just as great or more compared to the 1900s, with influence reaching policymakers and even the scientific community.

After all, it is known that major tobacco companies are going into the vaping and e-cigarette market and supporting studies related to vaping.

That said, even though vaping only entered the mass market over a decade ago, we can already form a confident picture that vape isn’t as safe as initially thought, or, at least how the vaping industry would like you to believe.

Though an older (2015) study by Public Health England (PHE) noted e-cigarettes as around 95% less harmful than tobacco, a more recent study (2021) by researchers from the Johns Hopkins University (JHU) found nearly 2,000 unknown chemicals in e-cigarette and vaping liquid, including known and potentially harmful compounds.

Though this is a lower amount than cigarettes, one of the JHU researchers and author of the said study correctly pointed out that “cigarette aerosols contain other completely uncharacterized chemicals that might have health risks that we don't yet know about” in a statement.

Even though longer-term impacts are less known, it is a fact that vaping liquid contains nicotine and various other toxins commonly found in cigarettes.

The mounting evidence linking acute respiratory diseases with vaping, many other health issues such as infertility and related health conditions involving the cardiovascular system, the various unknown chemicals and their physiological impacts, insufficient longer-term data and questionable independence of studies put into question the notion of a “safer” option of vaping compared to cigarettes, even in the near-term.

EMIR Research will elaborate more on these in a separate article titled as “What Makes Vaping Harmful?”. Suffice it to say here that shifting from smoking to vaping is likely trading a bad habit with serious health consequences with another.

Recommendations

If the intention is to discourage vaping, the reasonable step is to maximise taxation and regulate vapes and e-cigarettes just like tobacco i.e., maximising the sin tax rate, earmarking a bigger allocation to the health ministry, setting the highest age limit and putting in force the generational end game to stop vaping and smoking altogether.

Considerable risk of secondhand exposure also calls for vaping only in designated places, at a safe distance and location from the public.

Vaping liquid, ingredient mix and concentrations, atomizer technology, wattage and voltage would have varying health and safety profiles. Regulations must cover both vape liquid and the devices.

More studies should be done to provide finer details in vape regulation such as limitation to wattage and atomiser technology to minimise health harm, and voltage for safety reasons.

Depending on further studies, higher-powered devices of 50 watts and above should be banned and only consider devices below 25 watts as these contribute to the aerosol particle size that can impact biochemical and physical interactions in the body.

Another parameter that could be added as part of device and substance regulation is aerodynamic resistance, with restrictions on technologies and liquid combinations that result in higher resistance and longer residence time in the lungs as these can exacerbate deposition risk in the lungs.

The allowable base liquid for vaping and e-cigarettes liquid should also be studied. Current findings appear to indicate vitamin E acetate as a riskier option linking to e-cigarette or vaping product use-associated lung injury (EVALI). Other base liquids such as vitamin E oil, coconut oil and medium chain triglycerides (MCT) need further investigation.

There should also be a list of restricted ingredients and maximum ingredient concentrations in vape and a regulation to ensure additives and their concentrations are listed on the packaging. For example, this may include addictive stimulants such as nicotine and caffeine, known carcinogens and other restricted compounds.

Of course, this would require testing and monitoring capabilities for the regulation to be effective.

EMIR Research supports the call to put the collection taxes and the exemption of nicotine from the Poisons List on hold until the Tobacco Regulations and Control Bill is passed.

The Bill must be debated and should include the generational endgame provision alongside the consideration of EMIR Research’s recommendations above, which requires more studies to be done by the authorities to adequately evaluate vaping risks and come up with proper standards, regulations and means of enforcement.


* Dr Rais Hussin and Ameen Kamal are part of the research team of EMIR Research, an independent think tank focused on strategic policy recommendations based on rigorous research.

** The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the position of Astro AWANI.