The Saw Swee Hock School of Public Health, the National University of Singapore in their A Global Health White Paper Series has published “The Case for Tightening E-Cigarette Regulations in Southeast Asia” in 2021. Saw Swee Hock School of Public Health is an Institutional Member of the Asia-Pacific Academic Consortium for Public Health (APACPH). The executive summary of the publication is presented below and the full publication is available from the School’s website.
INTRODUCTION
E-cigarettes are products that heat a solution, commonly called ‘e-liquid’, to create a vapour which is inhaled (‘vaped’) in a similar manner as the smoke of a cigarette. It encompasses a broad category of devices, e-liquids and components that, when assembled, are used in a similar manner as tobacco products. The global market for e-cigarettes has proliferated from around $50m (USD) in 2005 to over $20b in 2019 and is expected to grow to $34b by 2024, with tobacco transnationals now owning a large proportion of the e-cigarette market.
E-cigarette use is controversial in terms of its safety, efficacy as an aid to smoking cessation, and potential as a gateway into smoking, especially for youth. E-cigarette companies have been reported to target youths in their marketing and product designs. Prevalence of youth usage more than doubled from 2017 to 2019 in the US, evidence of the success of such target marketing. E-cigarette policy responses vary considerably among countries — ranging from the precautionary implementation of a complete ban, to regulation of marketing and access, to promotion as a harm reductive alternative or effective cessation aid. This paper examines the e-cigarette situation in Southeast Asia (defined as the geographical region that includes Singapore, Indonesia, Malaysia, the Philippines, Myanmar, Thailand, Cambodia, Vietnam, Laos, Brunei, Taiwan, and Hong Kong).
THE HEALTH IMPACTS OF E-CIGARETTE USE
Although most of the evidence is from outside Southeast Asia, put together, it suggests that e-cigarettes are a safety hazard and, in the long term, may cause disease, while evidence on their efficacy as a smoking cessation aid, and potential to act as a gateway into tobacco use in youths, remain uncertain.
Safety
Recent studies on the health effects of e-cigarette use have shown an association with increased risks of cardiovascular and respiratory diseases, and generalised coughing and irritation in the airway. Specific to the region, surveys in Hong Kong and Indonesia reported a higher prevalence of respiratory symptoms and irritation to the eyes, nose and upper respiratory tracts in e-cigarette users. Beyond the cases reported in academic publications, diseases suspected to be e-cigarette-related, such as nose tumour, fluid in the lungs, lung damage and breathing difficulty, were reported in Malaysia, the Philippines and Thailand in 2019. In 2015-2018, cases of e-cigarette-related accidents involving explosions, burns and injuries to the face were reported in the Philippines, Malaysia, Indonesia and Brunei.
Although most experts agree that vaping is probably safer than combustible tobacco use, the long-term health impacts of vaping are unknown and some studies on the relative safety of e-cigarettes have been controversial due to methodological issues and conflicts of interest. Concerns have also been raised over the link between vaping and COVID-19, with e-cigarette users at higher risks of the disease and more severe disease progression.
Efficacy as a smoking cessation aid
Recently published research on the efficacy of e-cigarettes in smoking cessation have arrived at different conclusions. The 40 studies we examined spanned a wide variety of designs and included a range of participants (current and former tobacco users, e-cigarette users, dual users). Some were inconclusive (25/40, one from Malaysia), others found evidence for efficacy (9/40), and others concluded that e-cigarette use hindered smoking cessation (5/40) or had no association (1/40, from Hong Kong).
Youth use and gateway effect
Among the studies that examined the profiles of e-cigarette users in Southeast Asian countries (Malaysia, Taiwan, Hong Kong and Myanmar), all reported that e-cigarette users were more likely to be young in age, which is consistent with international reports of e-cigarette companies targeting youths. We looked at 12 recently published studies on e-cigarette’s potential gateway effect. The studies yielded mixed results ranging from inconclusive (5/12), evidence for the existence of a gateway effect (4/12, one each from Taiwan and Malaysia), absence of evidence of a gateway effect (2/12), and an association with a decline in youth smoking (1/12, from Taiwan).
Advertising and promotion of e-cigarettes in the region target youth
E-cigarettes were promoted at the point of sale using posters, billboards, banners and pamphlets, and displayed alongside common consumer products to help position them as lifestyle products. Advertising strategies to attract youth include cinema adverts, employing young and attractive brand ambassadors, sampling offers, sleek and trendy storefronts, and targeting venues frequented by youths.
E-commerce is a significant and growing sales channel in the region, with websites containing user-generated content being the preferred channels for promotional activities. As at June 2020, a large majority of the popular or featured brands in the region’s online stores were from China. Brands well-known in Western countries, such as Juul, Vuse, Blu, and MarkTen, featured rarely or not at all. In the region’s active e-cigarette markets, e-cigarettes were widely available in general e-commerce stores (e.g. Lazada, iprice) as well as e-cigarette specialty shops. Age-verification in these websites was either absent or lacking, making e-cigarettes easily accessible to youths.
E-cigarette devices often resembled items such as pens, perfume bottles, flash drives and small tech gadgets, and were positioned as lifestyle products. E-liquids had hip sounding names and trendy packaging, and were sold in a massive variety of flavours, most commonly fruits, desserts, beverages and tobacco flavours. The products were marketed with price promotions and user ratings.
E-cigarette markets in Southeast Asia are projected to grow
In Southeast Asia, the e-cigarette industry is nascent but already has a growing reach in some of the region’s markets. In 2019 e-cigarettes were sold in six Southeast Asian countries/territories (Malaysia, Indonesia, the Philippines, Vietnam, Taiwan and Hong Kong) with a total market value of $595.3m (USD). The total e-cigarette market in these places was projected to grow by 29% (to $766.3m) by 2023, mainly in Indonesia and the Philippines. The e-cigarette market in Indonesia is projected to supplant Malaysia as Southeast Asia’s largest e-cigarette market by 2021. E-cigarette markets in the Philippines and Vietnam have been growing steadily since 2013, and are projected to continue growing into the 2020’s. Taiwan and Hong Kong’s markets were significantly smaller with Taiwan’s market expected to remain stagnant. Hong Kong’s market was expected to close, likely due to a proposed tightening of e-cigarette regulations. However, Hong Kong’s market remains active due to the postponement of that legislative decision.
Contrasting policy responses across the region have led to different market scenarios
Southeast Asian countries vary considerably in terms of their e-cigarette policy responses. Singapore, Brunei and Thailand imposed strict bans pre-emptively, making regulation and ongoing refinement of the legislation easier from the outset. Laos and Cambodia acted early and issued directives to ban e-cigarette import, distribution and sales at an early stage before the e-cigarette market could be established.
Indonesia and Myanmar have no specific e-cigarette regulation, while the Philippines, Taiwan, Malaysia, Hong Kong and Vietnam have varying restrictions on e-cigarette availability, advertising, accessibility and use. The growing markets and ready accessibility of e-cigarettes in these countries suggest that current regulations are insufficient to prevent the entrenchment of e-cigarette use, especially among youths who are clearly a primary target of the industry.
More comprehensive e-cigarette regulations needed in Southeast Asia
To avoid e-cigarette markets from becoming established in the region, it is essential that Southeast Asian countries with weak policies covering e-cigarette access tighten their regulations. As e-cigarettes are products that potentially cause harm, and their efficacy versus safe, existing cessation aids such as nicotine replacement therapy is not yet conclusively proven, market access should only be granted when the uncertainties are adequately addressed. As a precautionary measure, e-cigarettes should be regulated while policymakers gather and deliberate the growing body of evidence. Delays to regulation allow e-cigarettes to gain deeper market entrenchment and will lead to a much bigger regulatory challenge in the long run.
