UP Medics: On Toys and Tobacco

Disclaimer: I am apathetic.

Yes, that is the sad truth. Don’t copy me fellow students. Generally, I am one apathetic, mind-your-own-business kind of girl. But every so often (example, another opinion column), my patriotic caring self is brought back to life. Let me just share to you how I got to writing this column. First problem: What’s the problem? Now being a clueless girl, I googled (yes, googled) current health issues in our country. The hits led me to the news section of our Department of Health (DOH), which then led me to the topic at hand, e-cigarettes.

I first encountered this interesting thing back in my Psych 115 class circa 2009, where my classmate was puffing away a.k.a vaping his electronic cigarette. I was quite amazed. There really is no smoke produced, just a smoke-like mist of water vapor, thanks to the magic of propylene glycol. The e-cig looked like a lollipop stick, slender and white. It can come with or without a nicotine cartridge, and different flavors like banana cream pie, milk tea, and strawberry cheesecake. It looked like a toy. Harmless I presumed. Let the boy vape away.

And boy was I wrong.

Or was I right?

This brings me to my second problem: Are e-cigarettes really harmful? The PMA and FDA now want to ban this seemingly innocuous thing. Since last month, the Philippine Medical Association (PMA) has been calling for a ban on e-cigarette sale until proper testing of safety has been done. The Food and Drug Administration (FDA) agrees since banning is more feasible than regulating the product. What is the e-cig anyway? Will FDA regulate it as a medical device? A drug? A tobacco product? It’s hard to regulate something when you don’t even know how to classify it.

Some studies say e-cigs are harmful; some say they’re not. Others say there is not enough evidence to say otherwise. A 6-month pilot study by Polosa and colleagues in 2011 found that e-cig users complained of mouth and throat irritation and dry cough which may be due to propylene glycol, a food additive commonly found in smoke generators in disco bars, theaters, and aviation emergency training. An infodemiological study by Hua, Alfi, and Talbot in 2013 found increased heart rate and palpitations, nicotine overdose symptoms like nausea and vomiting, changes in heart rhythm, confusion, dizziness, fatigue, or nicotine withdrawal symptoms like anxiety and depression. In ECLAT* randomized control study in 2013, shortness of breath was reduced. In a technical report by Burstyn in 2013, the tobacco-specific nitrosamines in e-cigs were found in trace quantities, which cause no measurable risk for cancer. The World Health Organization says there is no scientific evidence confirming product safety and efficacy as proven nicotine replacement therapy or smoking cessation aid. I agree. After searching the literature, the studies do seem to be inconclusive—no obvious and outright, “Yes! I am harmful” or “Yes! I am harmless”.

But let’s step back and look at the bigger picture: E-cig users stopped smoking tobacco right? Our Italian non-quitter friends actually reduced smoking, and some even completely abstained from it after one year of e-cig use, as seen in the ECLAT study. Isn’t that just awesome and in accord with our national smoking cessation program? Our program’s vision is to reduce the prevalence of smoking and minimize smoking-related health effects. Oh hi e-cig! You may be the solution. Let’s just ask our EBM friends (that’s evidence-based medicine you guys), for help on that. Does e-cig use reduce smoking in the Philippines? Is it harmful? I leave these questions to you.

Let’s go back to our PMA-FDA conundrum: To ban or not to ban, that is the question. I don’t know guys; I think I’m on the fence on this. A third problem comes to mind: When do you ban products anyway?

According to the FDA Act of 2009, the FDA can ban any health product that has caused death, serious illness or serious injury to a consumer or patient, or is found to be imminently injurious, unsafe, dangerous, or grossly deceptive. A health product, or specifically, a health-related device is any device not directly used in health care but has been determined by the FDA to adversely affect the health of the people, as the case may be with e-cigs. In the FDA Advisory No. 2013-008, FDA advises the public to not use electronic cigarettes because they say, among other things, that some e-cig marketers promote e-cigs as a “legitimate therapy for smokers trying to quit”. So, is FDA saying e-cig marketers are grossly deceptive? Looks like it. But Philippine E-cigarette Industry Association (PECIA) Vice President Joey Dulay says, “It’s not really a quit-smoking device. Harm reduction lang. We don’t market it as a smoking cessation device.” This may be true only for the 95 small-scale sellers of PECIA, and may not account for other vendors, like those in the street.

So in summary, e-cigarettes have been shown to be harmful in some studies, but harmless in others. E-cigarettes have helped with smoking cessation and reduction in other countries, but this has yet to be proven in the Philippines. FDA calls for a ban on e-cigs because of its unproven safety and efficacy, and false marketing by some e-cig sellers.

I think it all boils down to risk-benefit analysis. Will more people be harmed by e-cigarettes, or will e-cigs help in tobacco smoking cessation? Until the risk is proven to be greater than the benefit, I think a total ban of e-cigarettes is not warranted. A wise step I think is to regulate it either as a medical device or as a tobacco product. I think it is also prudent to research on e-cigs as a form of nicotine replacement therapy, such as nicotine patches and gums.

Electronic cigarettes as harmless toys? Or electronic cigarettes as harmful tobacco? Science will be the judge of that.

*EffiCiency and safety of an eLectronic cigAreTte (ECLAT) as tobacco cigarettes substitute

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