The Online Citizen A Community of Singaporeans 
The amendments to the Tobacco (Control of Advertisements and Sale) Act which have been approved by Parliament on Tuesday will see an introduction of a ban for people from buying, using and owning imitation tobacco products, such as e-cigarettes, e-cigars and e-pipes, which will likely be in force by next year. This basically extends the current ban on the sale, import and distribution of battery-powered devices that heat nicotine-infused liquids to produce a vapour for inhalation.
During the debate on the bill, a few Members of Parliament have raised questions on whether there can be a consideration on the total ban on e-cigs and alternative product and suggested alternative proposals such as the one by Non-consituency Member of Parliament, Leon Perera that only confirmed smokers be given controlled access to e-cigarettes as a means of smoking cessation and harm reduction.
In the closing speech delivered by Mr Amrin Amin, Parliamentary Secretary for Health brushed aside the concerns by the MPs by citing studies which are not named.
For example, Mr Amin said Mr Louis Ng’s reference to studies by Prof Linda Bauld that many people are using e-cigarettes rather than other available options to stop smoking, and it has been successful for a significant number of smokers. Mr Amin said that it was a cross-sectional study that looked at the situation at one point in time, which design is not suitable for studying the gateway effect.
He said, “There had been studies in the US, UK and Canada, which followed up on more than 40,000 youths over time, and found that e-cigarette users had a greater risk of becoming cigarette users. All these studies have found evidence to support the gateway effect.”
But according to Lynn Kozlowski, a professor at the Department of Community Health and Health Behavior in US, “There is little evidence that those who have never smoked cigarettes or never used other tobacco products and first try e-cigarettes will later move on to cigarette usage with great frequency or daily, regular smoking.” In a paper co-authored by Kenneth Warner, the Avedis Donabedian Distinguished University Professor of Public Health in Michigan’s School of Public Health, both former deans of their respective public health schools, highlights several shortcomings in studies that appear to show a link between e-cigarette use and subsequent smoking.
Noting that many studies use misleading measures for what is actually considered smoking. Kozlowski wrote, “Measures of ‘at least one puff in the past six months’ can mean little more than the experimenting vaper was curious how cigarettes compared,” and Warner adds that in one study, only four e-cigarette users who previously hadn’t smoked reported smoking cigarettes when measured again at a later time and highlighted various factors in studies on gateway effect inconclusive.
In response to Mr Perera’s reference to the 2015 report by Public Health England which states that e-cigarettes are 95% less of a health hazard to conventional tobacco consumption, Mr Amin states that the number of studies used by the report were of limited quality. He then went on to note that an editorial in the Lancet, a leading medical journal, has criticised the report for using weak evidence but did not mention what name was the editorial and when it was published.
Presumably, Mr Amin is referring to the editorial published in 2015, just a week after the report by PHE. The editorial wrote,
” First, there was a “lack of hard evidence for the harms of most products on most of the criteria”. Second, “there was no formal criterion for the recruitment of the experts”. In other words, the opinions of a small group of individuals with no prespecified expertise in tobacco control were based on an almost total absence of evidence of harm. It is on this extraordinarily flimsy foundation that PHE based the major conclusion and message of its report.”
MOH ought to note that following the publication of the editorial, there are those who wrote to the journal to express their disagreement. Take for example, Professor John Britton, who chairs the Royal College of Physicians Tobacco Advisory Group, co-chair the Public Health England Tobacco Control Implementation Board and a member of the board of trustees at Action on Smoking and Health.
In the response, “E-cigarettes, Public Health England, and common sense”, he wrote,
In response to your recent Editorial, it is obvious, from the assessment of the content of electronic cigarette vapour described by Ann McNeill and Peter Hajek in their report for Public Health England that electronic cigarettes are substantially less hazardous than tobacco cigarettes. Whether 95% as estimated by David Nutt and colleagues,3 or slightly less or more than that figure, does not matter: the obvious conclusion is that they are substantially less hazardous.
Smokers need as many ways out of smoking as they can get, and electronic cigarettes are one of them. Public Health England deserves credit for applying some common sense to this issue, and giving smokers a clear message that switching to electronic cigarettes will substantially reduce the harm they will otherwise sustain from continued smoking.
Mr Amin further said, “Some tobacco companies are pivoting from smoke-producing cigarettes to smoke-free but nicotine-containing products such as e-cigarettes and heat-not-burn tobacco products. They hired researchers and lobbyists to help them with this pivot. The form of nicotine delivery differs, but the revenue-generating base product is still nicotine. ENDS are marketed as “healthier” alternatives and youths are targeted. I think the danger of many more youths becoming addicted to nicotine is clear. We must not let down our guard. We must protect our young.”
That is what Dr Amy Khor said in Parliament too in Oct, “Studies show that high school students who use ENDS are more likely to move on to smoke cigarettes. To protect public health, Singapore has pre-emptively banned the import, distribution and sale of ENDS.”
Back in 2015, TOC interviewed a former smoker and store operator in London (video here), he shared that he had started smoking at the age of 13 and had quit smoking with the aid of e-cigarettes. When asked if e-cigs or vaping provides a gateway to conventional smoking, he disagreed. As at the point of the interview, he had already stopped adding nicotine into his vaping solution and merely a habitual practice, a trend which he observed in his customers.
In a recent 2017 survey conducted by Action on Smoking and Health (ASH) which is fully funded by the British Heart Foundation and Cancer Research UK and also receives project funding from the Department of Health to support tobacco control, estimates that 2.9 million adults in Great Britain currently use e-cigarettes (vape) up from 700,000 in 2012, the first year. It notes that for the first time there are more ex-smokers (1.5 million) who use e-cigarettes than current smokers (1.3 million). Over half (52%) of e-cigarette users are now ex-smokers and 45% are smokers. The survey points out that the main reason given by ex-smokers who are currently vaping is to help them stop smoking while for current smokers the main reason is to reduce the amount they smoke.
After quoting so many unnamed studies, what studies have MOH actually conducted itself?
Let us look at the facts:
- The conventional cigarette is proven to be harmful and cancer-causing, for the smoker and the 2nd-hand smokers.
- Cancer-causing agents from tobacco smoke come from burning of tobacco leaves not from the nicotine.
- While e-cigarettes and alternative tobacco products are not entirely risk-free, it is not as harmful as conventional cigarettes due to the above scientific fact.
Going back to Prof Kozlowski, he said, “The public deserves accurate information on the health risks of e-cigarettes versus cigarettes,” and added “From the best evidence to date, e-cigarettes are much less dangerous than cigarettes. The public has become confused about this.”
So what the MOH is insisting here is that as there is no evidence to prove (although there are many just that MOH does not wish to acknowledge) thate-cigarettes and alternative tobacco products are not as harmful and is a gateway to smoking, conventional cigarettes which is 100% harmful to the human body, both to smoker and by-standers should be allowed to used, with no other alternatives if smokers want a change. Simply to put, it is a quit or die mentality.
Ludicrous to aim for 100% elimination of smokers
“Our goal is not just a smoke-free future, but a nicotine-free one. So-called lesser-harm tobacco products still expose the user to toxic and addictive substances that are harmful to health.” said the Parliamentary Secretary. But let us be realistic, drug addiction has not turned people away from heorin nor AIDs turned people from unprotected casual sex. Banning e-cigarette is akin to banning any form of sweets which have the same properties of chewing gum, there are always be people who will seek to satisfy their need or curiosity. Just like how death penalty and severe punishment over the past decades have not eliminated the use of drugs in Singapore.
If national health is of the utmost importance, why don’t MOH set to ban conventional flame-to-burn tobacco cigarettes within the next few years and have e-cigarettes and heat-not-burn tobacco products such as Philip Morris’ ICOS introduced to reduce the health risk posed to smokers and the 2nd-hand smokers?
Can MOH with its belief system instead of scientific basis argue that alternative tobacco products are equal or more harmful than conventional cigarettes? If not, why the resistance towards embracing such new alternatives which are gradually gaining traction in developed countries?
Ultimately, MOH’s stubborn stance is likely due to a religious-like doctrine that smokers much quit or die as with abstinence to prevent sex diseases or the fear of loss in terms of taxation that can be obtained from the sale of tobacco to those who cannot quit smoking.
Public health authorities around the world who embrace the introduction of alternative tobacco products are in the mind that so long the health risk of the smoker and those around them can be reduced and a possible reduction in smoking of conventional cigarettes (proven to be cancer causing), vaping, e-cigarettes can be adopted with proper regulations.
Just as what the Director of Public Health for Hertfordshire, Prof Jim McManus said in his speech during the E-cigarette conference 2015, “Do we take a hermeneutic of suspicion or do we take a hermeneutic of generosity in a rapidly scientific world and I believe I need to take the latter otherwise I cannot do my job and serve the people who pay my wages.”, Before this, he professed that public health directors are more than often a jack of all trades and should listen to what the researchers have to say, something that MOH should think about.
He added that Hertfordshire will become as e-cigarette friendly as it can be, in recognition that the public health gains from e-cigarettes significantly outweigh the risks. “at the time were people are still dying from tobacco-related illness, surely the priority is to stop death, misery from tobacco (consumption) and not get obsessed with nicotine.”
Disclosure: TOC does not accept any form of financial benefit from any tobacco company. TOC was sent to London for a convention on e-cigs in 2015 along with a few other publications by a tobacco company but was not paid to write any articles or produce any material to promote e-cigs.