This Week in Asia

Why Hong Kong should accept e-cigarettes if it wants a smoke-free future

The Hong Kong government's plan to remove e-cigarettes and other novel tobacco products from the market by prohibiting their sale, import and marketing is a regressive step in tobacco control.

It is likely to hinder, rather than help, efforts to reduce the smoking rate to 7 per cent by 2025. While it may be psychologically comforting to think a hardline stance on e-cigarettes will reduce the harm done by smoking, the opposite is probably true. Why so?

First, there is growing consensus in the scientific community that not only are e-cigarettes less harmful than traditional cigarettes, they are also more effective in helping smokers to quit. An independent expert review commissioned by Public Health England, a government body in the United Kingdom, concluded in 2015 that e-cigarettes were about 95 per cent less harmful than tobacco smoking.

In the United States, the National Academies of Sciences, Engineering and Medicine looked at more than 800 peer-reviewed scientific studies on the health effects of e-cigarettes, and concluded in 2018 that "while e-cigarettes are not without health risks, they are likely to be far less harmful than conventional cigarettes ... and using e-cigarettes may help adults who smoke conventional cigarettes quit smoking".

The jury's out on whether e-cigarettes and vaping devices help or hinder efforts to ween people off smoking. Photo: AP

Most recently, a "randomised controlled trial" of 886 participants in the New England Journal of Medicine found e-cigarettes were twice as effective as conventional methods in helping smokers quit. The landmark study found the one-year smoking abstinence rate was 18 per cent for e-cigarette users, twice the rate for nicotine replacement therapy (NRT). The study is likely to have understated the real value of e-cigarettes as NRT is unpopular with smokers " only two to four per cent of smokers in any one year try NRT. By contrast, e-cigarettes are far more likely to be used by smokers to quit.

These studies notwithstanding, there is still insufficient evidence on the long-term impacts of e-cigarettes. Whether e-cigarettes would improve public health in the long-term is still unknown. As in many other domains, governments have to weigh potential pros and cons without the benefit of full information. In this instance, the health and environmental benefits of smokers switching to less harmful alternatives must be weighed against the costs of non-smokers using these addictive products as well as the risks of these products being a "gateway" to smoking.

The question before Hong Kong's legislators is whether this uncertainty justifies the extreme measure of a complete ban on the sale of these lower risk products.

Sophia Chan Siu-chee, Hong Kong's Secretary for Food and Health, discusses the proposed e-cigarette ban on RTHK. Photo: K.Y. Cheng

Besides the cost-benefit trade-off, there is also an ethical dimension. A puritanical approach to all forms of nicotine consumption is not helpful. Smoking is a deadly vice, but it is unlikely that the consumption of tobacco or nicotine could be eliminated. The aim of tobacco policy should therefore be harm reduction, rather than the unrealistic, utopian one of harm elimination.

The uncertainty over the long-term health impacts of e-cigarettes is not to be taken lightly. But a full assessment of the long-term health impacts of e-cigarettes would take many more years. Meanwhile, the harm caused by smoking is happening now. By banning products that are now recognised by scientists to be much less dangerous than cigarettes, the authorities may be preventing an achievable reduction of death and diseases.

Third, it is quite perverse that the most harmful version of tobacco products " traditional cigarettes " is widely available, while a less harmful version is taken off the market. Hong Kong prides itself on its free market economy. An essential feature of this is consumer choice and sovereignty. While there is often a case for government paternalism and restrictions, this should apply only to market failures " such as when transactions cause harm to third parties. Unlike conventional cigarettes, e-cigarettes are mostly harmless to bystanders. A ban on lower risk alternatives not only deprives smokers of the choice to switch to something less harmful, it also forces non-smokers in this densely populated city to inhale the toxic fumes of smoking.

As e-cigarettes entail both social costs and benefits, the sensible approach would be to put in place regulations that allow society to capture some of their benefits while minimising their costs. This would mean, for instance, allowing e-cigarettes to be sold only in specially licensed stores and marketed only to smokers, and not to children, teenagers and non-smokers.

A man vapes in Wan Chai. Photo: Winson Wong

Fourth, the risks of the so-called "gateway effect" have been overstated. The studies purporting to show that vaping increases the risks of smoking often conflate association with causation. That someone who has experimented with e-cigarettes goes on to smoke does not mean that it was the former that caused the latter; the person might have picked up smoking without e-cigarettes.

Even if the gateway effect exists, the sensible response is not a ban on the sale of e-cigarettes. It is to devise regulations that shrink the size of the gateway. For instance, the authorities could set a higher legal age (say 23) for buying e-cigarettes than for cigarettes. This would reduce risks of gateway effects since it is unlikely that prospective smokers would wait to the higher age to experiment with e-cigarettes.

If the evidence later shows that e-cigarettes are a useful cessation device and do not produce the long-term harm that public health authorities fear, the legal age could be lowered to match that of conventional cigarettes. These lower risk products can also then be regulated more lightly than cigarettes. On the other hand, if they are found to be more harmful than thought, regulations can be tightened. Indeed, this is how governments should respond to new technologies or products that entail both benefits and risks to society.

A ban on e-cigarettes could make it harder to wean people off real cigarettes. Photo: Winson Wong

Finally, a ban on smoking alternatives ignores the psychology of addiction. Many smokers find it very difficult to quit not just because they are dependent on nicotine, but also because the routine of smoking makes quitting difficult. If smoking is a psychological condition, not just a physiological one, harm reduction is more likely if smokers replace their bad habit with one that is similar in routine but is much less harmful. To the extent that these lower risk products mimic the experience of smoking (but without most of smoking's harms), allowing smokers to switch is a more promising strategy than insisting on abstinence.

The Food and Safety Bureau's goal of reducing the smoking rate to 7 per cent by 2025 is a laudable one. But it requires a two-pronged strategy: a tougher stance on smoking " through taxation and measures to de-normalise smoking " and efforts to make lower risk products available to smokers. Doing the latter, in fact, allows the authorities to pursue the former more vigorously.

The longer-term vision should be to create a smoke-free future in which tobacco smoking is eliminated altogether (not just reduced to 7 per cent), and anyone who wishes to consume tobacco or nicotine would have to do so through products that are much less harmful than today's cigarettes.

Donald Low is Professor of Practice and Director (Leadership and Public Policy) at the Institute of Public Policy, Hong Kong University of Science and Technology

This article originally appeared on the South China Morning Post (SCMP).

Copyright (c) 2019. South China Morning Post Publishers Ltd. All rights reserved.

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