by Dr. Tan Kok Kuan
The recent outbreak of vaping related lung illnesses in the US, some even leading to death, has thrown into doubt the safety of e-cigarettes, once hailed to be the answer to the smoking epidemic. The concept of harm reduction in tobacco use is not new and tobacco companies have had a long history in trying to develop products that deliver nicotine without the toxins. Recent advances in technology have been instrumental in promoting this endeavour.
In the 1950’s, smoking cigarettes were believed to be good for your health. Cigarettes were sold to patients by their bedside in hospitals by nurses and Doctors endorsed them. However, it soon came to light that cigarettes greatly increases the risk of many diseases including the two biggest killers in the world today, cancer and heart disease. Seeing their revenue and profits shrinking, the tobacco industry tried to develop “less harmful” tobacco products such as “light” and “low tar” cigarettes. However, despite the transnational tobacco companies’ best efforts to perpetuate this lie, it soon became apparent that these products were just as harmful as their predecessors. Not ready to give up yet, in the 1960’s R. J. Reynolds developed a novel device called the Premier which heated rather than burned tobacco. Over the years other companies including Japan Tobacco International and Philip Morris International attempted to develop similar products. However, none of them turned out to be a commercial success mostly due to poor user acceptance.
In 2003, a pharmacist in China Professor Hon Lik developed the first nicotine vaporizer. This gave birth to a novel way of inhaling nicotine collectively known as electronic nicotine delivery systems or by their more common name, e-cigarettes. E-cigarettes were hailed as the answer to the smoking epidemic. They allowed users to continue using nicotine and mimic many of the sensations and rituals of smoking while exposing users to significantly fewer toxins as compared to cigarette smoking.
This concept of tobacco harm reduction by e-cigarettes was fully embraced in the United Kingdom. The National Health Service actively encouraged smokers to switch over to using e-cigarettes. Many other countries in Europe as well as the United States allowed the use of e-cigarettes albeit with various levels of controls and regulations. Countries in the Asia Pacific region however took a very different tack. Countries including Thailand, Taiwan and most recently India banned the import and sale of e-cigarettes. In Singapore, even the possession and use of e-cigarettes is illegal with offenders liable to spend up to 12 months in jail. One of the key reasons cited for these bans is that we do not yet know the possible long-term effects of using e-cigarettes. Singapore’s Senior Parliamentary Secretary for Health and Home Affairs stated that the ban was a “precautionary measure” as “there is no data on long-term health effects of using e-cigarettes as these are relatively new products.” This sentiment was echoed by lawmakers in India.
These fears were recently given new credence when a mysterious vaping-related lung illness swept across the United States. Young, previously healthy adults who used e-cigarettes developed cough, shortness of breath and difficulty breathing. Some progressed to respiratory failure requiring them to be placed on machines to take over the function of their lungs. At the time of this report, more than 2600 cases have been reported with 57 fatalities. Most of the cases were linked to the addition of Vitamin E acetate as a cutting agent for THC (tetrahydrocannabinol) to the vape fluid and using vape fluids procured from illicit sources. However, a number of patients also reported using only nicotine containing e-cigarettes.
This has understandably worried regulators The Centres for Disease Control, US has recommended that e-cigarettes users stop using vape fluids that contain THC. While the UK continues to voice its support for e-cigarettes, countries like Malaysia that currently do not have specific regulations for e-cigarettes are calling for them to come under the same laws that govern tobacco. South Korea also advised its citizens to stop using e-cigarettes and is speeding up its investigations into whether or not to ban its sale. China, which has the world’s largest tobacco market, is also considering imposing controls on e-cigarettes and e-liquids.
This has focussed the attention back on heated tobacco products. Since the demise of the Reynolds Premier, heated tobacco devices have progressed to become sleek electronic devices that mimic most of the sensations and rituals of smoking. The amount of nicotine delivered is also similar to smoking cigarettes and all these have made them much more acceptable to users. What’s more, unlike e-cigarettes, heated tobacco products uses tobacco as a nicotine source. This makes them much more difficult to tamper with. Heated tobacco products also potentially exposes users to fewer toxic chemicals as compared to smoking.
A market in which heated tobacco products have really taken off is Japan where almost five percent of smokers have made the switch. Interestingly, e-cigarettes that contain nicotine are banned in Japan making it a unique environment for nicotine users. This has created a natural experiment from which valuable lessons can be learnt. As yet there are few independent studies. Industry associated research found a significant decrease in cigarette sales after the introduction of heated tobacco products and predicted a decline in overall morbidity and mortality attributed to smoking. What is perhaps most significant is an independent paper published by Dr Osaki of Tottori University that found negligible uptake of heated tobacco products among middle and high school students. In an unusual regulatory environment, Japan may have serendipitously stumbled upon the solution to the smoking crisis.
The Asia Pacific is suffering disproportionately from smoking related diseases. The WHO estimates that one fifth of people in the region are smokers and there are one million deaths every year from cardiovascular disease caused by tobacco use. E-cigarettes once thought to be the panacea is now floundering from increased pressure to ban their use due to the questionable safety of their long-term use. Perhaps it is time for a different technology, that of heated tobacco, to have its turn at attempting to reverse the tide of the smoking epidemic.
Disclaimer: The views expressed here are the contributor’s and does not reflect the views of Asia-Pacific Biotech News or any other company. This article does not promote or support the use of tobacco products. The best choice any smoker can make is to quit smoking completely.
- Osaki et al., Field survey on drinking and smoking and the development of effective alcohol reduction intervention approaches for the prevention of lifestyle-related diseases
- Caviedes, Ivan & Labarca, Gonzalo & Silva, Claudio & Fernandez-Bussy, Sebastian. (2019). Marijuana Use, Respiratory Symptoms, and Pulmonary Function. Annals of Internal Medicine. 170. 142. 10.7326/L18-0614.
Dr Tan Kok Kuan, Chief Medical Officer, Republic Healthcare