The e-cigarette world map looks like a giant patchwork quilt; different countries are struggling to find the right path between no restrictions, or varying restrictions and partial or complete bans.
The public health community is deeply, and often acrimoniously, divided about whether e-cigarettes could do great good or great harm. Reasoned questioning can result in unjustified and aggressive personal attacks. It is not unknown, but it is uncommon, to have such ferocity and personalization of a medical issue. There is no consensus even among respected public policy experts, institutions and academics — although World Health Organization (WHO) advocates a precautionary approach — and this is leaving both policymakers and smokers confused.
The problem is that governments have to act before the science is conclusive. We lack robust science on the ingredients, the long-term harm, whether they help smokers quit or continue the habit, and whether they encourage youth initiation. It will be years — and perhaps many decades — until science reveals some of the answers. Remember, we are still discovering new harmful health effects from ordinary cigarettes, which have been on the market for 100 years, and thoroughly researched for over 50 years.
While it is generally felt that e-cigarettes are less toxic than cigarettes, the ingredients are often unknown and very variable (some are toxic), because they aren’t regulated. A recent analysis of e-cigarettes by the Hong Kong Baptist University found they contained carcinogens, hugely varying levels of chemicals, and many of those labeled as containing no nicotine were found to do so.
We also need more research on environmental exposure levels of chemicals in e-cigarettes — in the same way that we now know that environmental tobacco smoke has an effect on neighboring non-smokers. A deeper concern is that e-cigarettes present a latent danger of re-normalizing the acceptability of smoking in society. There have been signs that increasing numbers of young people are taking up vaping thinking that it is a less harmful alternative to smoking even though science is far from conclusive on this presumption.
Contributing to this re-normalization in countries like the US (although not yet seen in the Hong Kong SAR), the tobacco companies, which own almost all of the major vaping companies, have been aggressively promoting e-cigarettes with images reminiscent of 1960’s tobacco advertising with connotations of health, glamor, attractiveness, slimness, popularity, sportiness, cool or machismo.
Should they be promoted in a regulated way if they were proven to aid quitting? To date, there isn’t sufficient evidence on their effectiveness, and virtually no studies from low- and middle-income countries and regions. There are many contradictory claims: “Electronic cigarettes helped between 16,000 and 22,000 more people quit smoking in England in 2014” (Addiction journal), while a review of 15 studies reported in the Lancet concluded that e-cigarettes did not lead to more people giving up smoking.
The concern is that smokers might be lulled into a false sense of security and continue with dual-use (smoking and vaping), rather than the much healthier option of quitting smoking completely.
What are governments to do?
There are some actions on which all agree. E-cigarettes should be incorporated into all monitoring of tobacco prevalence, harm and attitudes — including youth uptake, dual use, and their effect on cessation. Hong Kong included e-cigarettes, for the first time, in the 2015 prevalence survey. Other areas of agreement include requiring disclosure of ingredients or testing by a government chemist (although few countries have the technology to do this), and clear standards for ingredients. Government should, at minimum, ban the promotion of all unproven health claims, ban marketing and sales to youth, and require warning labels on packets and equipment.
In Hong Kong, all e-cigarettes containing nicotine are banned under an old law, and smoking e-cigarettes in smoke-free areas is illegal. Sales of non-nicotine containing cartridges are legal, but cartridges containing nicotine are not, and come over the boundary from the Chinese mainland. If the labeling is as erroneous as the Baptist University study suggests, then it is virtually impossible for the public to know if an e-cigarette contains nicotine or not. The Hong Kong government has proposed strengthening the existing legislation and prohibiting the import, manufacture, sale, distribution, and advertising of all e-cigarettes, whether they contain nicotine or not.
It is not the first time, and will not be the last, that governments have to make decisions when they do not possess all the evidence. Until robust science on e-cigarettes unites the public health community in Hong Kong, and worldwide, the jury is still out.The author is an Edinburgh medical doctor, based in Hong Kong since 1967. She is senior advisor to the Vital Strategies/Bloomberg Initiative, senior policy advisor to WHO, and director of the Asian Consultancy on Tobacco Control.