WROTE on May 9 how electronic cigarettes (e-cigs) may be both a blessing and a curse. They represent a potential step in reducing the danger posed by cigarette smoking, an epidemic that continues to plague our society with considerable drainage of financial and medical resources. On the other hand, e-cigs may glamourise and encourage individuals to take up smoking, especially among our youth.
E-cigs have gained popularity as a replacement for normal cigarettes despite not being approved or supported by most medical societies. The rationale to allow unfettered public access to e-cigs is based on harm reduction — it is hoped that smokers do not develop diseases, such as lung cancer, by switching to a product that ostensibly contains safer materials. It is also being reviewed as a tool to aid smoking cessation, i.e. as a “step down” prior to quitting tobacco consumption.
A few small clinical studies have demonstrated that e-cigs can decrease the desire to smoke, as well as the number of cigarettes smoked per day. However, the drop in cigarette consumption was mostly not sustained after six months. Dr Amer Siddiq of Universiti Malaya’s Centre of Addiction Sciences pointed out that most participants in e-cig smoking cessation studies were unable to quit smoking, although the quantity might have been reduced. It is clear at this stage that larger, unbiased trials are needed to ascertain the role e-cigs have in smoking cessation, both in terms of effectiveness and long-term safety. The latter is particularly important given the lack of transparency into manufacturing practices and e-cig contents.
The issue of safety becomes more paramount when we look at e-cigs from a public health perspective. Tobacco companies are barred from advertising cigarettes, but e-cigs are a new product with the potential for mass marketing. It is worth bearing in mind that its primary content, nicotine, is highly addictive. Instead of aiding in smoking cessation, there is a risk that non-smokers (especially children and teenagers) may decide to try a product that they falsely believe to be benign.
Among youth, e-cigs use is more likely to be found with those who are experimenting or already using normal cigarettes. However, in 2012, 20.3 per cent of middle school and 7.2 per cent of high school e-cig users in the United States were first-time users of nicotine products. An earlier study in South Korea reported that 15 per cent of e-cig users in grades 7 through 12 never smoked a cigarette.
Perceptions of a product’s safety and danger are heavily influenced by marketing. Claims that a product is healthier and “cleaner”, especially if endorsed by a celebrity, may incorrectly lead a user into believing that the consequences of inhaling nicotine are negligible. This is especially so among susceptible youth, who are juicy targets for companies, as nicotine addiction might lead to lifelong customers.
It is, therefore, unsurprising that the United Kingdom’s Committee of Advertising Practice, who write and maintain UK advertising codes, have announced new advertising rules for e-cigs to ensure that they are promoted responsibly. The rules are to protect youth, with emphasis on avoiding advertisements that spin tobacco products in a positive light.
Under the rules, advertisements must not appeal to those below 18, especially by reflecting or being associated with youth culture; people shown using e-cigs or playing a significant role must neither be, nor seem to be, under 25; advertisements must not be directed at people under 18 through the selection of media or the context in which they appear; advertisements must not encourage non-smokers or non-nicotine users to use e-cigarettes and it must be made clear that the product is an e-cig and not a tobacco product.
Advertisements on TV and radio will be subject to scheduling restrictions and, just as importantly, advertisements cannot claim to health benefits or safety unless authorisation is given by the Medicines and Healthcare Products Regulatory Agency. In practical terms, they will have to await the publication of more in-depth research before spouting claims of healthcare benefits.
These tentative steps are welcomed in the UK as we navigate unchartered waters. The plan would be to monitor the effect of the rules with the aim of conducting a formal review after 12 months. However, it is worth bearing in mind that there is no regulation for advertising online, where many e-cig companies have a significant presence. With widespread advertising on social media, it remains the parents’ responsibility that they engage their children on the content that they may come across.
Malaysia is likely to look at the experiences of other countries prior to introducing legislation of our own. In the meantime, we should remain critical in our approach, and not view the introduction of the e-cig as a panacea for cigarette smoking.
The jury is still out on the matter, and, as we await more definitive data, we should continue to make our youth aware of the dangers of nicotine addiction.