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E-cigarettes - a potent mix of danger for the young

SINGAPORE - Mango lassi, honeydew, lychee and even bandung - these are just a taste of the myriad regional flavours which can now be smoked in Malaysia.

And the explosion in flavours, which also include Red Bull, Yakult grape and milk tea, shows how much the use of e-cigarettes has grown across the border and why there is now a major and very heated debate there on how to regulate it.

Earlier this month, a nationwide raid on e-cigarette shops came in the wake of Malaysia's Health Ministry deciding that only licensed pharmacists and medical practitioners would be allowed to sell the flavoured e-liquids containing nicotine.

Some believe this does not go far enough.

Lawyer R.S.N. Rayer, an MP in Penang with the country's largest opposition party, the Democratic Action Party (DAP), called for shops in Penang to be shut for good, saying his own son was tempted to pick up the habit, and claiming that it could lead to drug abuse.

But businesses cried foul, saying the clampdown came at the behest of tobacco companies afraid of losing customers to the new kid on the block, and that it denied smokers the chance to move to "less" harmful means of nicotine use.


ST ILLUSTRATION : MIEL

In Singapore, the sale, import or distribution of e-cigarettes are banned, but they are still sometimes illegally sold through local online channels. And there are worries that as the popularity of e-cigarettes continues to grow across the Causeway and many other parts of the world, the youth here will also come to see e-cigarettes as safe and hip.

SO IS IT SAFE?

The e-cigarette industry has been at pains to distance itself from traditional tobacco cigarettes and the cancer-linked chemicals they contain to play up the image of e-cigarettes as a safer alternative.

E-cigarettes are called vaporisers and the nicotine-laced liquid that is turned into vapour by a heated coil and inhaled is termed juice. Users do not smoke, they vape - a word that was Oxford Dictionaries' Word of the Year in 2014, given its use had doubled from the year before.

In fact, the industry has seen phenomenal growth since a pharmacist in China invented the e-cigarette in 2003 and his company started making it two years later.

What was a US$20 million (S$28.4 million) market in 2008 is now worth US$3 billion, and is expected to at least triple by 2017. Analysts have predicted that the industry could well overtake the tobacco business over the next 30 years. The Malaysian E- Vaporizers and Tobacco Alternative Association estimated that vape sales reached US$639 million last year. 

But science has fallen behind, and competing claims from sources such as e-cigarette advocates, celebrities and studies make the extent of the harm of these devices confusing. And there are currently no standards for makers of the devices and e-liquids to adhere to.

What are usually listed as ingredients in juices are propylene glycol, which is a permitted food additive, glycerin, water, nicotine and flavourings. That said, labels may not be accurate either. While commonly accepted food flavourings may be used to create the eclectic flavours, it is not known what happens when these are inhaled instead of eaten.

A simple search on the Internet can turn up as many articles for "vaping", as e-cigarette smoking is called, as against it.

Britain's public health authority, Public Health England, issued a report last year that said e-cigarettes are not only 95 per cent less harmful than regular cigarettes, but also have the potential to help smokers quit. But other research say that e-cigarettes could have harmful effects that are similar to tobacco smoking.

According to a Japanese study, e-cigarettes contain up to 10 times more cancer-causing substances than regular tobacco. "Especially when the... wire which vaporises the liquid gets overheated, higher amounts of those harmful substances seemed to be produced," researcher Naoki Kunugita said.

Dr Wong Seng Weng, medical director of The Cancer Centre, said e-cigarette users are exposed to nicotine, which is addictive, as well as heated and aerosolised propylene glycol and glycerol, which may turn into carcinogens.

Studies show that nicotine causes a short-term increase in blood pressure, heart rate and blood flow from the heart. It also causes the arteries to narrow.

The World Health Organisation also said in a 2014 report that vaporisers can contain cancer-causing agents and toxicants and, in some cases, as much as those in conventional cigarettes.

Addiction and cancer-causing agents aside, e-cigarettes have blown up in people's faces, and in New York, a one-year-old child died after ingesting juice.

Beyond the long-term health aspects of e-cigarettes, which will take time to ascertain given they have been around for a short time, there is a bigger concern - their appeal to young people.

PROTECTING THE YOUTH

E-cigarettes are normalising smoking among the young, making it more acceptable. First, there is the perception that they are safer than regular cigarettes since they were meant to get people off smoking. This is helped by scores of YouTube videos and Instagram pictures by vaping celebrities and other advocates, who make it look fun by blowing smoke rings. And instead of the bad smell of tobacco, vaping has no odour at all - which means it is also easier for the young to not get caught by their parents.

To top it off, juices come in candy flavours, such as bubble gum, cotton candy and cheesecake, a tactic some activists have called appalling. According to various reports, China, where the sale of e-cigarettes is unregulated and where they are available for as little as US$3, young children are being hooked through such candy flavours.

Anti-smoking advocate and senior consultant respiratory physician Philip Eng said: "They (e-juices) come in different colours, different flavours. There's a possibility it's harmless, so it's attractive to young people."

The US Centres for Disease Control and Prevention reported that the use of e-cigarettes among middle school and high school students aged 11 to 18 tripled from 2013 to 2014. Similarly, in survey results released in August this year, Action on Smoking and Health found that 13 per cent of 11- to-18-year-olds in the United Kingdom had tried e-cigarettes at least once, up from the 5 per cent in 2013. Last year, the New England Journal Of Medicine published a study labelling e-cigarettes a "gateway" through which teenagers get addicted to nicotine and possibly move on to more harmful addictive drugs.

Such is the growing concern in Malaysia that Education Minister Mahdzir Khalid this week warned that school children caught vaping can face expulsion. This comes after numerous videos were posted on social media showing school children using e-cigarettes.

The situation in Singapore is less alarming. Dr Caroline Balhetchet, who works with at-risk youth and delinquents, said vaping has not caught on among most teenagers she has come across.

"They (e-cigarettes) are not very accessible and they are expensive. It's a lot easier for teenagers to get traditional cigarettes," she said.

But with the increasing popularity of vaping elsewhere and more students going overseas, there are worries that it will undo all the work that has gone into turning the young away from smoking. Dr Ong Kian Chung, a respiratory medicine specialist in private practice, said it could "sabotage" these efforts.

Citing studies in the US, he said: "E-cigarettes may serve as a bridge to smoking conventional cigarettes. Kids who have tried e-cigarettes were a lot more likely, about eight times more likely, to smoke conventional cigarettes."

A version of this article appeared in the print edition of The Straits Times on November 19, 2015, with the headline 'E-cigarettes - a potent mix of danger for the young'. Print Edition | Subscribe