31 January 2019
Singapore has banned e-cigarettes to protect the public from the harm they can cause, said Senior Parliamentary Secretary for Health and Home Affairs Amrin Amin, as he laid out a comprehensive explanation for the Government’s policy. Speaking at a Health Promotion Board roadshow on Jan 26 to launch a campaign on the dangers of e-cigarettes, he also cautioned against taking the words of “so-called experts” on the subject at face value. Below is an excerpt of his speech.
In a 2018 Health Promotion Board survey of 600 youth, over 70 per cent of youth were unaware that e-cigarettes contained nicotine and cancer-causing chemicals, and their vapour contained fine particles (also known as PM 2.5) that could cause respiratory diseases. What this campaign seeks to address is the information gap on the harms of e-cigarettes.
There is a worrying global trend on the use of e-cigarettes, especially among youth. We have to ensure that our public and young know the facts, and understand the reasons why we have banned Electronic Nicotine Delivery System, or ENDS, which include e-cigarettes.
Let me briefly share why.
Let’s start at looking at international developments. Let’s look at the use of e-cigarettes in the United States and Hong Kong.
In the US, the Food and Drug Administration declared that youth use of e-cigarettes has reached epidemic proportions.
There are some 3.6 million underage users of Juul and other e-cigarettes — and mind you, these are just the underage numbers, minors, very young people.
Between 2011 and 2018, there’s been an upsurge in e-cigarette use among US middle and high school students (secondary school students here).
Nearly 21 out of every 100 high school students surveyed report e-cigarette use in the past 30 days – this is according to data from the US Centre for Disease Control and Prevention.
Colourful packaging, flavouring and other strategies were used by tobacco industry to target young people and present these products as less harmful than they actually are.
Nearer to home, in Hong Kong, the tobacco industry has been lobbying health authorities to regulate e-cigarettes like other tobacco products, or in short, not to ban them.
Hong Kong relaxed the use of e-cigarettes, allowing it to be used as a pharmaceutical product since 2009.
However, the data from Hong Kong showed a worrying trend — more young children were experimenting with e-cigarettes.
There was a 55 per cent rise in the proportion of Primary 2 to 4 students trying e-cigarettes in the last two years.
Medical societies and groups in Hong Kong therefore pushed strongly for a ban against e-cigarettes due to health risks to the young.
Hong Kong recently announced that they will be banning e-cigarettes. This is aligned with our position, along with 27 other countries.
BAN A PRECAUTIONARY MEASURE
In Singapore, the importation and sale of e-cigarettes have always been banned under the blanket prohibition on imitation tobacco products. In 2017, we extended the ban to cover purchase, use and possession.
The comprehensive ban is intended to protect the public from the harms of emerging tobacco products.
Some of you have asked why not ban cigarettes, like we have done for e-cigarettes. If indeed all tobacco products are harmful, why not ban cigarettes too?
Is it because the Government wants to make more money from taxes that we impose or levy on cigarettes? The answer is no. Taxing cigarettes is actually meant to discourage consumption.
If we have our way from early on, we probably would have banned cigarettes at the outset. But it would be very challenging to do it now and let me tell you why.
Cigarettes are entrenched tobacco products globally, including in Singapore. About one in 10 Singaporeans are addicted to tobacco products, and they will need time and support to quit.
The banning of cigarettes, given the existing pool of smokers, will give rise to black markets and increase the flow of smuggled cigarettes into Singapore.
Instead of a ban, the World Health Organization (WHO) has recommended that countries adopt a comprehensive mix of strategies including public education, smoking cessation services, advertising restrictions, sale restrictions to minors and taxation, to bring down smoking prevalence.
For e-cigarettes, WHO recommends that countries take necessary measures to protect their population from the harms of such products, including regulating and banning them.
We do not want new tobacco products to come into Singapore as they could become entrenched and drive up the overall use of tobacco in our population.
Some of you may ask if e-cigarettes are bad for your health. You may come across reports in media of smokers switching to them for supposed “health benefits”.
Let’s be clear. E-cigarettes are harmful.
Nicotine, found in e-cigarettes, is toxic and it can harm parts of the brain that control attention, memory and learning, and may result in permanent lowering of impulse control.
Nicotine can also adversely affect the heart, reproductive system, lungs and kidneys.
Nicotine is also highly addictive. That’s why it is difficult to quit smoking cigarettes and e-cigarettes. You can get hooked to e-cigarettes and later on, other tobacco products.
In fact, a number of studies conducted in the US, Canada, Poland, and United Kingdom have shown that e-cigarette use was associated with experimentation with cigarettes among youth.
Youth who have used e-cigarettes are more likely to become regular smokers. This is what is known as the “gateway effect”, where e-cigarette users eventually transitioned to smoking cigarettes, or continue to use both tobacco products interchangeably as dual users.
Besides nicotine, e-cigarettes also contain other harmful cancer-causing substances such as benzene and heavy metals such as lead.
There is no data on long-term health effects of using e-cigarettes as these are relatively new products. There’s virtually no research on how e-cigarette vapour affects lungs in youth over the long term.
So our advice is don’t take chances. Be familiar with the facts, don’t be seduced by half-truths or lies!
It’s your health we are talking about. E-cigarettes are not harmless.
DIVERSIFICATION AND SO-CALLED EXPERTS
Tobacco companies are investing billions of dollars in developing new products that could move the industry beyond cigarettes.
The evidence on cigarettes are clear, convincing and irrefutable. A new tobacco-based product appears to provide a diversification option and an additional revenue stream.
So we see today e-cigarettes and heated tobacco products being promoted as “smokeless” tobacco products that are healthier than cigarettes.
The e-cigarette industry is increasingly dominated by the tobacco industry and it is hard to make a clear distinction between the two.
For example, tobacco giant Altria, which makes Marlboro and other brands of cigarettes, is now a big shareholder of Juul, a major manufacturer of e-cigarettes in the US.
The tobacco industry is strong at lobbying. When you hear so-called experts sharing their views — do ask whether they are being funded or influenced by tobacco lobbyists.
In the 1960s and 70s, so-called experts funded by the tobacco industry tried to water down the evidence linking smoking and disease.
Tobacco companies used their research to claim that there is no “scientific causality”, “conclusive proof”, or “scientific proof” that smoking causes diseases like lung cancer.
Where are these experts today and what are they saying now, given that it is clear and irrefutable today, and there is conclusive, convincing scientific proof on the harms of cigarettes, linking smoking to various diseases — cancer, for example.
Lung cancer is the top risk factor for cigarette smokers.
This is an important lesson. Don’t take the words of so-called experts without studying the evidence.
We have to do what’s right for our people. It’s our public duty and responsibility.
QUESTION OVER EFFECTIVENESS FOR CESSATION
Another argument we often hear is e-cigarettes should be allowed as they can help smokers to quit. Let me share our current thinking on this.
First, public health authorities are divided on whether e-cigarettes can help smokers to quit. Some countries, like the UK and New Zealand, are supportive of this.
But the evidence for the use of e-cigarettes as a smoking cessation aid is actually mixed and limited.
Unlike Nicotine Replacement Therapy (NRT) products, there is no clinical trial evidence showing e-cigarettes’ safety and effectiveness in smoking cessation.
In fact, it is quite common for smokers to use both e-cigarettes and cigarettes together. Certainly, this does not reduce their risk of smoking-related diseases.
While there are clinical trials looking at the safety and effectiveness of ENDS for smoking cessation, none has reported conclusive results thus far.
If there is indeed evidence of their usefulness as a smoking cessation aid, Singapore is willing to study them.
There is a mechanism for it, a scientific mechanism and not a PR machinery or a campaign.
Manufacturers can apply to register their product as a NRT product under the Health Products Act, for it to be legally available in Singapore. We have yet to receive any applications thus far.
Second, there are many approved smoking cessation aids — you do not need e-cigarettes to quit.
There are safe and effective methods such as smoking cessation counselling, and the use of NRT, for those who need a little more encouragement and help.
There’s also the HPB’s Quitline for smokers to get more information and support for their quit journey.
Third, there are practical challenges if we restrict e-cigarettes as cessation aids. Recall how e-cigarettes are marketed as lifestyle products and flavourings.
There is always the risk that non-smokers and the young can get hold of them. Look at the Hong Kong experience.
Monitoring who is supposed to have e-cigarettes and who is not, and limiting access to non-smokers and the young would present significant challenges.
Given the highly questionable efficacy of e-cigarettes as a smoking cessation device and the fact there are many smoking cessation aids already available plus the challenges I have highlighted, we are taking a prudent course in banning ENDS, with public safety and interest firmly on our minds.
If there is good and sound evidence to prove otherwise, we are happy to review it.