Only a handful of countries in the world have embraced the use of e-cigarettes. These include the USA, the UK, and New Zealand. On the other hand, about 40 countries or jurisdictions have already banned these products completely. This is particularly true of middle- and low-income countries, which are still struggling with the existing combustible-cigarette epidemic, and do not want to introduce an additional and new form of tobacco into their markets.
Accumulating evidence has led over 100 countries to implement laws regulating e-cigarettes, related to minimum age of sale; bans on e-cigarette advertising, promotion and sponsorship; child safety packaging, pack warnings and labeling requirements; product regulation such as nicotine levels, safety, ingredients or flavors; taxation; and bans on vaping in smoke-free areas.
E-cigarettes are not safe products. We don’t even know the many different ingredients in a wide range of vape products. Some contain nicotine, some not. Studies in Hong Kong have shown that labeling is often misleading; for example, labels state they contain no nicotine where they do, and vice versa.
These products cause harm to all ages, especially youth. These harms range from addiction and cancer, immune, mental, oral, reproductive, respiratory and cardiovascular effects to a significant risk to pregnant women users, as the products damage the growing fetus.
Vaping greatly increases the risk of catching COVID-19 and also leads to worse health outcomes, even in youth vapers. A study at Stanford University in the USA found that adolescent vapers were up to seven times more likely to catch COVID-19 than non-vapers. Concern has also been raised about COVID-19 being transmitted by exhaled vape clouds.
There may be more to come. Traditional cigarettes have already been on the market for 100 years and evidence on their harm is still accumulating, so there will be more data on the harm of e-cigarettes in the future.
We should not just rely on studies on harm and death, or the toxicology of the ingredients. Social science studies report that e-cigarettes act as a gateway to youth later taking up ordinary cigarettes. The first report in Asia was published in 2019 on 13,000 students in Taiwan, China — teen vaping doubled the odds of youth taking up cigarette smoking two years later. The World Health Organization has also warned that e-cigarettes could act as a “gateway” to tobacco consumption. It said a global systematic review found that children and adolescents using them are more than twice as likely to later use conventional cigarettes.
Do e-cigarettes help smokers quit? With those who are already cigarette smokers, e-cigarettes encourage continuation and dual use, and longer studies show they are not helpful in aiding smokers to quit smoking. A report in the then-28 European Union countries published in 2018 found the opposite: “E-cigarettes are associated with inhibiting rather than assisting in smoking cessation.” A 2021 meta-analysis of 64 papers on the topic concluded: “As consumer products, in observational studies, e-cigarettes were not associated with increased smoking cessation in the adult population.”
E-cigarettes also “re-normalize” tobacco use in society, just as cigarette prevalence is falling in most countries. They are perceived as trendy, but many don’t realize they include embedded software, designed to monitor smoking behavior.
Advertising of these new products, for example in the USA, is reminiscent of the atrocious cigarette ads in the 1960s and 1970s. It is clearly aimed to encourage youth to start vaping, rather than what the industry claims — that they are targeting middle-aged smokers trying to quit.
We need to be skeptical about tobacco-industry claims. The industry has previously misled governments, the community and its customer-smokers by stating that filters and low tar were “safer”, yet this turned out to be untrue.
What of the Chinese mainland, Hong Kong and Macao?
The Chinese mainland: E-cigarettes were first conceived in the Chinese mainland. Today, the Chinese mainland holds a leading edge in the global e-cigarette industry, with over 90 percent of the world’s e-cigarettes manufactured on the Chinese mainland. As the harm of e-cigarettes has become evident, China has undertaken research on e-cigarettes. In 2022, after a debate as to which organization should regulate e-cigarettes on the Chinese mainland, e-cigarettes were moved under the direct control of the State Tobacco Monopoly Administration, which means they will be under the same rules as those governing the sale of ordinary cigarettes. Under the new regulations, e-cigarette manufacturers and sellers will have to acquire licenses from the government. Other laws involving e-cigarettes are being passed with some rapidity — the 2020 Law on the Protection of Minors, bans on sales near schools, imminent bans on non-tobacco flavors, and laws and regulations at the city level.
Hong Kong: The city banned the import, manufacture and sale of e-cigarettes (and heated tobacco products) in 2021. One veteran legislator said he had never witnessed such intensive political lobbying on any topic as by the tobacco industry attempting to prevent this ban. But the public, health groups, parents and teachers were all in support of the ban.
Macao: A 2017 ban prohibits the sale and advertising of vaping products but does not criminalize their consumption.
What should governments do? If an outright ban is not possible, virtually all public health experts agree it would be incautious of any government to allow these products unrestricted on the market. Measures would include:
1. Including e-cigarettes in all monitoring; for example, prevalence, harm, attitudes, economic impact.
2. Monitoring safety and effect, especially youth uptake, dual use, and effect on cessation.
3. Requiring disclosure of ingredients and set standards, or undertake government testing.
4. Banning sales to those younger than 21 years old.
5. Banning promotion of all unproven health claims.
6. Banning marketing and sales, especially to youth.
7. Requiring rotating, graphic warning labels on e-cigarette packets.
8. Banning vaping in smoke-free areas.
Harm reduction has a historical place in public health, as in methadone maintenance in heroin addiction, or the wearing of safety belts in cars, or the use of condoms. Harm reduction has also been misinterpreted as using e-cigarettes instead of conventional cigarettes, thus replacing a very harmful product with a less- but still-harmful product. The concept is intuitive and attractive and therefore very tempting for smokers, health professionals and politicians. Unfortunately, this is a one-sided view of a much more complex public health problem. Once e-cigarettes become established in societies, it will be almost impossible to eliminate these still very real hazardous products. New tobacco products do not protect public health.
The author is a special adviser to the Global Center for Good Governance in Tobacco Control, a senior policy adviser to the World Health Organization, and director of the Asian Consultancy on Tobacco Control.
The views don’t necessarily represent those of China Daily.