Globally, the sales of e-cigarettes have surged exponentially by over 120-fold, from USD20 million in 2008 to USD 3.5 billion in 2015. In Hong Kong, vaping and e-cigarettes are also well-received, particularly by the younger population.

Dr Ning Fan, Chairman of Health In Action (HIA), shared with MIMS his worries over the growing threat of e-cigarettes in Hong Kong in an interview in November this year. He warned that we might already be too late in preventing an epidemic of e-cigarette use in light of the accessibility and popularity among the younger population.

The Hong Kong government is also aware of the growing threat of e-cigarettes. Earlier this year, Professor Sophia Chan, the Under Secretary for Food and Health at that time, had been discussing the legislative arrangements with relevant departments regarding an amendment bill to tighten the regulation on e-cigarettes. With Chan now being the new Secretary for Food and Health, it is expected the policies will only come sooner rather than later.

E-cigarettes can bypass regulation by claiming nicotine-free

At present, according to the records of the Department of Health (DH), there are no nicotine-containing e-cigarettes registered as pharmaceutical products in Hong Kong. Neither has the department received an application for e-cigarettes containing nicotine for sale or distribution in the city.

Nevertheless, such figures do not necessarily mean that e-cigarettes containing nicotine do not exist in Hong Kong. There is a possibility that some e-cigarette products may claim themselves ‘nicotine-free’ on the packaging to bypass the regulation.

“Although the government’s census and thematic surveys have included e-cigarette users in their analysis of smokers, is the number underestimated because e-cigarettes are unregistered in Hong Kong?” questions Fan in an interview with MIMS.

Even though the e-cigarette products do not contain nicotine, studies have discovered they might carry other harmful substances, including formaldehyde and benzo(a)pryene – both are cancer-causing agents, which promote the growth of cancer cells.

Commissioned by the Hong Kong Council on Smoking and Health, a team of researchers from Hong Kong Baptist University (HKBU) looked into the chemicals inside a total of 13 types of commercially available e-cigarettes. The results were worrying. Despite the zero nicotine claim on the packaging, the study found out they actually contain nicotine levels ranging from 3.5 to 28.5ng/ml.

Other harmful chemicals found included polycyclic aromatic hydrocarbons (PAHs), a highly carcinogenic by-product released when burning petroleum. The level in the e-cigarettes was found to be at least 1 million times more than roadside air in Hong Kong.

Also identified is the presence of polybrominated diphenyl ethers (PBDEs). “Associated with thyroid hormone disruption, inhalation of PBDEs may affect fertility and physiological development. It is also a neurotoxin, so it is definitely harmful to the human body,” remarked Dr Shan-Shan Chung, Assistant Professor of the Department of Biology.

Critics condemned government’s decision in considering a complete ban on e-cigarettes

On the other hand, opponents against the idea of a complete ban have expressed their dissatisfaction towards Chan’s initiative. Critics claims that e-cigarettes are actually safer for smokers as the PAH levels in 1ml of e-liquid is actually much less than the PAH in one tobacco cigarette.

They also accused Chan of not engaging in discussions with the vaping community. “Half of some 650,000 smokers are condemned to death by Sophia Chan for her refusing to talk to any of us and she should get out of the office for not doing her job,” said John Boley, co-founder of FactAsia, a non-governmental organisation that advocates for the rights of smokers. “Vaping is a very large part of the nicotine alternative. Consumers have chosen it, so why on earth should you stand in the way?” added Heneage Mitchell, also from FactAsia.

Vaping was claimed to be a healthier alternative to nicotine
Vaping was claimed to be a healthier alternative to nicotine

Meanwhile, the United Kingdom was highly praised by many for its method of dealing with e-cigarettes. Their multifaceted approach enlisted the cooperation of the healthcare sector, the Public Health department of England, tobacco researchers and civil society organisations as well as e-cigarette consumers.

“We have 2.9 million e-cigarette users in the UK, 8 million smokers. Of the 2.9 million, a million have stopped smoking. This is a huge public health success at no cost to the government,” said Professor Gerry Stimson, director of Knowledge-Action-Change, a UK advocacy group for smoking rights. “My advice to governments is to avoid jumping to legislation when all the concerns about e-cigarettes can be dealt with as you would deal with other consumer products,” he added.

An academic in the field of e-cigarettes, Professor Riccardo Polosa, suggested that the rule-maker should carry out further investigation before coming to a conclusion. “If the public is misled about the risks of e-cigarettes and other products that have the harm reduction potential, millions of smokers will be dissuaded from switching to these much less hazardous alternatives,” he explained.

However, Hong Kong is not the first region to consider a complete ban on e-cigarettes. According to the Hong Kong Council on Smoking and Health, a total of 13 countries have already imposed a complete ban on e-cigarettes, including Singapore, Thailand and Brazil.

Rampant usage among adolescents and young children

The modern-cigarettes do not have a long history. Invented in the 2000s by a Chinese pharmacist Hon Lik and the first manufacturer being established in Hong Kong, whether it can be used as a mean to quit smoking is still in debates. According to the Federation of Medical Societies of Hong Kong, there is “no evidence that e-cigarettes are risk free”.

“While evidence on the long-term effects of e-cigarettes is inconclusive, particularly on the question of whether they are carcinogenic, there is sufficient evidence of their short-term adverse effects, particularly on the cardiovascular and respiratory systems,” Fan said. 

Regardless of the conclusion, e-cigarettes should be kept away from adolescents and especially young children, although seemingly this is not the case happening in Hong Kong.

A local media once spotted a 6-year-old girl puffing away at an e-cigarette, alarming the public and igniting a heated discussion on how to stop this worrying trend.

A study published by the University of Hong Kong (HKU) found that 1.1% of over 45,000 secondary school students were current e-cigarette smokers – an alarming figure given the low prevalence of smoking in Hong Kong. In addition, 15.8% of e-cigarette users are between ages 15-19, which is a higher amount than those using e-cigarettes aged more than 30 years.

Authorities worry that the normalization of smoking with e-cigarettes could lead to many using it as a stepping stone to tobacco smoking.

Another study published in June 2017 suggested a stronger regulation to curb the use of e-cigarettes among youth. The study, conducted by researchers in the United States, tried to investigate the relationship between the initial use of e-cigarettes and subsequent cigarette smoking by conducting a systematic review and meta-analysis of longitudinal studies on 17,389 adolescents.

For those who have used e-cigarettes before, results revealed the pooled odds ratio for subsequent cigarette smoking initiation was 3.62 greater than young adults who have never used e-cigarettes before. This pointed to a greater risk for subsequent cigarette smoking initiation associated with the use of e-cigarettes. MIMS

(Editor’s note: This article has been updated on 8 November, 2017)

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