Fortunately, the Malaysian Health Minister Datuk Seri Dr S. Subramaniam has had the good sense not to listen to deranged health campaigners and is taking expert advice from a technical committee that will report by the end of August. The committee is chaired by Datuk Dr Abdul Razak Muttalif, Director of the Institute of Respiratory Medicine.
Here is my letter to him.
31 July 2013
Dear Dr. Abdul Razak Muttalif
I understand from press reports that you are conducting a review of the health impacts of e-cigarettes to help to inform the policy of the Government of Malaysia. This is vital work: it is quite possible that e-cigarettes will eventually stop the global epidemic of tobacco related disease and prevent millions of cases of cancer, cardiovascular disease and respiratory illnesses caused by smoking. This relatively new technology could prove to be one the most significant public health interventions of the 21st Century. Any decisions taken by the government will be of international significance, and with your permission I would like to represent a view from outside the country.
So I am writing to urge you to advise the government of Malaysia to take a positive approach to the great potential of e-cigarettes. Any move to ban these products or to restrict them excessively would without doubt be harmful to public health, causing more smoking than there would otherwise be. I am sure you will be well equipped to survey the literature in this area, so I would like to summarise briefly what I think it means for sound public health policy. I would also recommend reading an excellent short guide to framing this issue by Professor Lynn Kozlowski, Dean of the School of Public Health and Health Professions at the State University of New York at Buffalo: 9 things to think about when thinking about e-cigarettes . If you could provide clear, non-technical but authoritative advice similar to this, then I believe you will have done your minister a great service and contributed to the development of sound public health policy in Malaysia. If you would like to see how many top experts regard this issue, please browse my collection of quotes: Reasonable people saying sensible things about low risk alternatives to smoking .
The potential. E-cigarettes have great potential to reduce the expected toll of tobacco-related death an disease in the 21st Century. The WHO anticipates one billion premature deaths from tobacco on current trends would arise this century. Smoking is widespread and growing around the world – there are approximately 1.1 billion smokers in the world today, and if current trends continue, that number is expected to increase to 1.6 billion by the year 2025. Approximately 40% of men in Malaysia smoke, and any of those smokers would see immediate health benefits from switching to e-cigarettes if that was possible for them. Even in many OECD countries where there has been decades of determined public health campaigning and regulation, around one in five adults smoke – and the decline that was evident from the 1940s onwards has slowed in the last ten years. Almost all of the harm that arises from smoking is through the system of administration: the burning particles of tobacco, hot toxic gases and products of combustion that are the smoke. The drug itself, nicotine, is relatively benign – probably like caffeine in its risk profile. A product that can provide a satisfying dose of nicotine, fulfil some of the compulsive behavioural rituals or smoking, but deliver almost none of the risk associated with cigarette smoking clearly has great potential. Some investment analysts now see e-cigarettes overtaking cigarettes within a decade in the US and Europe. If that happens and is replicated in the rest of the world, then we will have one of the greatest public health revolutions in history.
The benefits. We already know much about e-cigarettes: what is in them, how they work and how they are used. E-cigarette sales have been growing at an extremely high rate worldwide from a small base, and there are many eloquent testimonies from “vapers” detailing how important these products are to them as alternatives to smoking. There is increasingly robust evidence from trials and surveys showing these products to be effective alternatives to smoking. Users like these products and are willing to switch. Unlike many public health policies, no coercion, restrictions or public spending is involved. What lies behind this success is that they are an effective alternative to cigarettes for nicotine users, but with very low health risks. They work because they deliver a satisfying dose of nicotine, some of the sensory experience and have similar behavioural rituals. This is very different from the function of NRT medicines, which deliver a slower background dose of nicotine to help relieve cravings during an effort to quit smoking and nicotine use completely. This is a fundamental difference. E-cigarettes are alternatives to cigaretteswith a number of desirable characteristics for continuing nicotine users. These include: much lower long term health risks; immediate benefits in well-being and quality of life; no second hand smoke impact on others; minimal fire risk; less mess and usually lower cost. These are substantial public health benefits and should be exploited to the extent possible. The idea ofpreventing potential users having access to these products by banning them in law raises serious ethical questions.
The risks. E-cigarettes should not be assumed risk free, but given what is in them and how they are used they are likely to be very low risk relative to cigarettes – two orders of magnitude (about 99%) less hazardous would be a reasonable assumption based on what is known already. The most serious risk arises not from use, but accidental ingestion of nicotine e-liquids – and can be mitigated with tamper proof packaging. The FDA of the United States found that they can contain residual contaminants or nitrosamines – but so do NRTs and many foods at similar levels. The concentrations are at levels so low as to be of little concern. These risks are likely to be small and manageable compared to what we know of the burning hot tar particulates and toxic gases taken into the lungs through cigarette smoke. There is no evidence that these products appeal to children – but even if they did, they may be used as an alternative to smoking and in any case cause minimal harm if teenagers do go on to use them into adulthood (something they are free to do with cigarettes). The claim that they ‘renormalise’ smoking has no basis – the use of e-cigarettes in public places has the beneficial effect of normalising a much safer alternative to smoking. In that sense it promotes an alternative to smoking that is beneficial to smokers. There is no basis for restricting by law the use of e-cigarettes in public places or workplaces – the products do not cause harm to third parties. At the same time there should not be a right to use them anywhere - it is up to the operators and owners of public places and workplaces to decide, and not for the government to impose regulations.
The unintended consequences of a ban or excessive regulation . The likely result of denying or limiting smokers alternatives to smoking that have proved effective and valuable elsewhere is more smoking than there would otherwise be, as people are unable to adopt strategies to quit or switch using these products. Any proposal to ban or excessively restrict e-cigarettes is in effect a proposal to protect the incumbent cigarette industry from competition from high-tech alternatives with superior characteristics. Why would government of Malaysia wish to do that? A further likely unintended consequence would be growth of an unregulated black market. Citizens are not passive about their health and would be likely to seek out supplies through back street or internet sales – that might include legal products bought illegally or more dangerously, illicitly produced products made from mixing e-liquids or other home-made preparations. I hope you will reflect on the likely unintended consequences of any ban or excessive regulation – it will be risky for health and sponsor criminal enterprise.
The ethics of a ban. There is a strong argument to leave these products to develop as rapidly as possible and to take market share from cigarettes. If people want to sell them, people want to buy them, they are much less risky than cigarettes and they comply with norms of consumer protection – like being acceptably safe, working as intended (ie not faulty), and not described in a misleading way – then what is the ethical basis for a ban or excessive restrictions on e-cigarettes? Nicotine is a widely-used legal recreational drug that in itself is almost harmless (comparable to caffeine), so why obstruct a much less dangerous way to take it with huge regulatory burdens that do not apply to cigarettes? When the state denies a smoker a product that could save their life, the state becomes complicit in the mortal consequences that follow from that decision. The are no precedents in other areas of consumer protection or health policy and no ethical basis for banning a much safer alternative to the dominant high-risk tobacco-based nicotine products.
What to do? The government should take the positive potential for e-cigarettes seriously, both for the beneficial effect it will have within Malaysia and for the signal it will send worldwide. There is potential to raise awareness and confidence in these products by establishing a framework of light touch consumer based regulation, covering electrical safety, tamper-proof packaging for e-liquids, correct disclosure of nicotine content and reasonable purity standards for e-liquids. Through the normal interplay of market forces, consumers will work out which products work, and these will become successful low risk alternatives to smoking. In most countries existing consumer protection law should be sufficient to achieve these modest objectives. Marketing should be permitted and efforts made to normalise these products as alternatives to smoking, by allowing their use in public places – and thus encouraging smokers to switch. If Malaysia does that, it will be taking a modern, forward looking approach to ‘harm reduction’ – that will be good for health and establish Malaysia as an international leader. I should stress that the greatest health benefit will come from having products that smokers start using instead of cigarettes – not from having over-regulated medicalised products that are safe, but dull and unappealing.
Disclosure . I have no competing interests. I have a long history of involvement in tobacco control starting in 1997, previously as director of Action on Smoking and Health (ASH-UK). I was one of the main NGO leaders who helped to bring the WHO Framework Convention on Tobacco Control into being in the period up to 2003. I have retained an interest ever since, though I have been working as a civil servant for the last ten years. Please be assured my sole interest in writing to you is in reducing the burden of tobacco-related disease and death in Malaysia and globally. These are my own views and not necessarily those of any past employers.
I would be delighted to assist you further in your efforts to define policy for e-cigarettes and thereby to secure the best public health outcome for Malaysia. I have not provided detailed references for the points set out here, but if I can assist you with more detail, I would be happy to.