The vaping debate

After a dozen vaping-related deaths due to mysterious lung illness in different states of the US, the Centres for Disease Control (CDC) has urged consumers to avoid buying vaping products from the street and to refrain from using THC oil or modifying/adding any substances to products purchased in stores.

The CDC has also advised that adults who used e-cigarettes containing nicotine to quit cigarette smoking should not return to smoking cigarettes. It also warned youth and young adults not to use e-cigarette, or vaping products.

This warning is also relevant to Pakistan where the ongoing youth bulge has found a new fantasy in vaping, and e-cigarette shops are propping up in different high-end localities. Prices range from Rs1500 for the simplest e-cigarette to Rs20,000 for the latest Personal Vaporising Mods. Prices of e-juices start from Rs700 for a 10ml bottle up to Rs4000 for a 100ml bottle.

With 6.7 million drug addicts, 15.6 million adult cigarette users, Pakistan is at high risk. These estimates are seven years old. Electronic cigarettes – or e-cigarettes – are also called vapes, e-hookahs, vape pens, tank systems, mods, and electronic nicotine delivery systems (ENDS). Using an e-cigarette product is commonly called vaping. E-cigarettes work by heating a liquid to produce an aerosol that users inhale into their lungs.

The liquid used in vaping can contain nicotine, tetrahydrocannabinol (THC) and cannabinoid (CBD) oils, and other substances and additives. THC is the psychoactive mind-altering compound of marijuana that produces the ‘high’. The chemical is an oil derived from vitamin E. Some reports suggest that these chemicals are secured from the black market.

However, the CDC says that the specific chemical exposure(s) causing lung injuries associated with e-cigarette product use, or vaping remains unknown at this time and are still under active investigation and laboratory scrutiny.

Nicotine is a highly addictive, potent drug, which can generate rewarding psychoactive effects even at very low doses. Cigarettes are a particularly effective form of nicotine delivery. When the smoke from a cigarette is inhaled, nicotine in the tobacco is rapidly absorbed into the lungs and carried to the brain.

According to the World Health Organization (WHO), nicotine was the primary addicting chemical common to combusted and non-combusted tobacco products and that it should be regulated, with other content and design features.

Cigarette burns (combusts) shredded tobacco leaves to generate smoke. Now the tobacco industry has come up with non-combusted products saying that smoke contains nicotine, which occurs naturally in tobacco, as well as many harmful chemicals. It is these harmful chemicals – not the nicotine – in cigarette smoke that are the primary cause of smoking-related diseases.

The tobacco industry, therefore, has come up with a range of heat-not-burnt products, claiming these are safe.

According to Britain’s National Health Service (NHS), a publicly funded national healthcare system, ‘they aren’t entirely risk-free, but they carry a small fraction of the risk of cigarettes. E-cigarettes don’t produce tar or carbon monoxide, two of the most harmful elements in tobacco smoke. The liquid and vapour contain some potentially harmful chemicals also found in cigarette smoke but at much lower levels’.

Public Health England’s 2015 independent evidence review found that, based on the available evidence, vaping is around 95 percent less harmful than smoking. The Royal College of Physicians came to a similar conclusion in its 2016 report ‘Nicotine without smoke: tobacco harm reduction.’ An estimated 2.9 million adults in Great Britain currently use e-cigarettes, and of these, 1.5 million people have completely stopped smoking cigarettes.

In the US, the FDA regulates ENDS, which have massive penetration there. The FDA says that among middle and high school students, 3.62 million were users of e-cigarettes in 2018. E-cigarette use, from 2017 to 2018, increased 78 percent among high school students (11.7 percent to 20.8 percent) and 48 percent among middle school students (3.3 percent to 4.9 percent) from 2017 to 2018.

According to a 2013-2014 survey, 81 percent of current youth e-cigarette users cited the availability of appealing flavours as the primary reason for use. Another argument is that it is because of flavours that conventional smokers are attracted to ENDS because cigarettes have a bad odour.

India, on the other, has taken the opposite approach by banning e-cigarettes. “It is very obvious that cigarettes and smoke-less [tobacco] are more harmful [than e-cigarettes],” says Ravi Mehrotra, chief executive officer of the Indian Council Of Medical Research’s India Cancer Research Consortium, which supports the e-cigarette ban.

“More than 65 percent of our population is less than 35 years of age, so why do you want to bring in more harmful substances when we already have others?” said Mehrotra. “People are also taking up smoking [regular cigarettes] to leave addiction of e-cigarettes, which is harmful. So better to avoid it, rather than getting into that which is unproven and has no positive health effects.”

When asked why the government has decided to ban e-cigarettes and not regular cigarettes, Preeti Sudan, secretary health and family welfare said that this step is being taken to contain the threat that e-cigarettes could pose for the future generations.

The WHO is also trying to set lower nicotine standards in cigarettes to make them non-addictive. Currently, the WHO says, most conventional cigarettes contain 10–15 mg of nicotine each, of which approximately 10 percent is delivered in smoke, resulting in a typical systemic intake of 1–2 mg of nicotine per cigarette. Higher levels can be delivered with more intense smoking behaviour. Thus, establishing a maximum allowable limit for nicotine would require an overall reduction in nicotine intake of the order of 90-95 percent or more.

“Setting standards for the levels of nicotine above which addiction is likely and below which addiction is less likely is vital in the development of reduced nicotine cigarettes. Although a clear threshold has not been defined yet and individual differences in sensitivity to nicotine should be accounted for, various studies indicate that decreasing nicotine content to 0.4 mg/g would minimize the risk for dependence,” the WHO adds.

E-cigarettes represent one of the most rapidly changing facets of the nicotine ecosystem. The category constituted about 1.9 percent of the global nicotine ecosystem in 2018 by retail value, which was up from 1.5 percent in 2017. In 2015, JUUL had zero market share. The company had less than one percent of the global vaping category share in 2016. That number, according to Euromonitor, increased to 3.9 percent in 2017 and 18.4 percent in 2018. All other significant e-cigarette producers either retained or lost share position in 2018.

A smoker can quit cigarettes by using nicotine replacement therapy (NRT) products, but global statistics are showing that retail sale of ENDs has far surpassed the NRT.

Pakistan, a nicotine producing and narcotics transit country, is at a policy crossroads. It has to choose from American, British, or Indian or a mixed approach. But one decision is to be taken urgently – to ban the sale of ENDS and cigarettes to children and enforce it with full force.

The writer is a freelancecontributor.

Email: nadympak@hotmail.com