Life & Art
Our non-sensical approach to vaping
Taiwan’s policy on regulating the alternatives to tobacco smoking, generically called “vaping”, is non-sensical. The latest policy changes are a knee-jerk reaction to powerful lobbies and fly in the face of evidence worldwide.
By Lee Faulkner
The amendments to the Tobacco Hazards Prevention and Control Act (THPCA), which took effect on 22 March, are a mishmash of bans and controls over alternatives to traditional tobacco smoking but leave the original sin largely untouched. They are the government’s response to a vocal and well-funded anti-tobacco lobby, and will produce wildly inconsistent treatment between existing and new methods of nicotine delivery. We need legislation that actually goes with the grain of public health policy rather than just wanting to appear to do so.
The aims of public health policy on smoking
For as long as I can remember, and that’s at least 50 years, the aim of government public health policies worldwide has been to get as many people as possible to stop smoking. The medical evidence about the dangers of smoking, first published in the 1950s, is incontrovertible. In the developed world those policies have been largely successful - whether by banning tobacco advertising and tobacco company sponsorship of sports and other events, or banning smoking in public places, or by taxing tobacco punitively to make it prohibitively expensive, smoking rates are significantly lower now than they were previously. In Taiwan today fewer than 15% of the population smokes, the vast majority of them being men.
Some countries have policies that aim to eliminate smoking altogether; for example New Zealand recently passed legislation that will annually raise the minimum age at which you can buy cigarettes, a “generational approach” that aims to stop anyone born after 2009 ever smoking. I have my doubts whether such draconian prohibitionist policies will work, and history would support my point of view - banning something tends to push it underground, with the black market fulfilling the market need. But let’s see.
The keys to these successful public health policies have been to thwart the marketing aims of tobacco companies, and to educate people about the health risks and social stigma attached to smoking. A new recently-arrived piece of armour to get people to quit has been to provide alternatives that, while still delivering nicotine, are thought to be less harmful overall.
Alternatives to traditional tobacco smoking
While the alternative ways of delivering nicotine to the body are commonly lumped together and described as “vaping”, there are in fact three very different product types available today:
1. “Real” vaping - a synthetic nicotine “e-liquid” is atomised and then inhaled.
2. THP (Tobacco Heating Products) - what looks like a mini-cigarette is inserted into a device and then heated to generate an aerosol for inhaling.
3. Oral nicotine pouches - nicotine is stored in a pouch which you then put in your mouth for a slow-drip nicotine release.
Note: the first two are sometimes referred to as “e-cigarettes”.
The common purpose is to let you get your nicotine fix in a non-combustible way with zero, or significantly reduced tar and other toxicants coming with it. As such, each of these alternatives is designed to be a much less harmful substitute for smoking tobacco. And yet, although the purpose is the same, the approach being taken by the Taiwan government to each is completely different - vaping and pouches made up of synthetic nicotine are to be banned completely, but THP and pouches containing tobacco are to be regulated as OTP (Other Tobacco Products). Not only is this approach inconsistent between existing tobacco smoking and alternatives to it, it is completely arbitrary between those alternatives too.
What does the science say?
The problem with scientific evidence on vaping is that it doesn’t say anything definitive about it simply because it can’t - there just hasn’t been enough time for studies to take place and for enough detailed evidence to emerge. Some studies which claim to be “long-term” only cover periods of between a few days and 12 months, far too short when you consider that the diseases associated with smoking take decades to emerge not months. Proper studies will need to address the huge complexity and granularity of risk factors required for modelling all of this - age, sex, socio-economic situation, access to health care, dual users (those who both vape and smoke) vs ex-smokers vs never-smoked, duration since using or quitting tobacco, and so on.
Another major problem is who carries out and funds these studies - either tobacco companies want to assuage their guilt for past behaviour by proving that their new products are the solution we’ve all been waiting for, or the anti-tobacco lobby won’t countenance any research on harm reduction alternatives because it’s philosophically welded to a “zero-harm” approach. Independence of thought and activity is essential, but so is funding, and a lot of it is needed.
Not being able to prove something means you can’t disprove it either; we can either wait for substantive studies to report back or rely on what evidence is already available and combine it with our best judgement - the Taiwan government isn’t doing either.
There are two risk assessments that we need to make - is the availability of alternatives to tobacco smoking causing the behavioural changes necessary for people to quit smoking, and are the alternative products any safer than tobacco?
The most common reason given for banning alternatives to traditional tobacco products is that they aren’t really substitutes - tobacco smokers will keep on smoking, the argument goes, but the availability of the substitutes will create a whole new “starter market” for nicotine addiction for those who don’t currently smoke. People, particularly youngsters, will be tempted to have a try of these new products just for the hell of it, and then become addicted and, worse still, start dabbling with real tobacco smoking.
A 2020 study by the E-Cigarettes Working Party of my professional body, the Institute and Faculty of Actuaries, found no evidence that a starter market had taken place since the widespread availability of alternatives over recent years. But neither did it find any evidence that it hadn’t happened; so, in short, the study was inconclusive, and more time is needed to draw conclusions.
There is some evidence, however, that e-cigarettes are more effective at helping people quit smoking than NRT (Nicotine Replacement Therapy). From a 2019 study in the UK, 54% of vapers are ex-smokers, 40% are dual users and 6% never smoked; apart from backing up the argument that if there is a “starter market” it’s pretty small, it does provide evidence that the alternatives can and do help people quit smoking. Even if only a tiny percentage of existing smokers were able to give up smoking by using alternatives then that is a benefit to be cherished and expanded not removed by banning those alternatives. Is our public health policy designed to help people stop smoking cigarettes and pipes or to stymie them?
Are alternatives more harmful?
There does seem to be plentiful evidence that e-cigarettes are less harmful than normal tobacco smoking; again, the evidence is not definitive because a lot more studies and time are needed, but I am not aware of any studies that show that e-cigarettes are more harmful. The harm of vaping falls somewhere along the line between the risk of traditional cigarettes and the risks for people who never smoked, but exactly where along that line is not certain.
As with studies of behaviour, coming up with irrefutable evidence to support or contest points of view is immensely difficult, and a whole host of related and ancillary risks muddy the waters considerably. But we can either keep our minds open and watch the evidence as it emerges, or we can close down our willingness to be informed, which is what the Taiwan government is doing.
Does banning things ever work?
As I’ve said, by banning alternatives you are removing an option for people who want to try quitting smoking, and that runs directly contrary to public health policy. What also makes no sense is why we try banning people’s habits that have no effect on anyone else. The lessons of history are abundantly against banning things in this way.
If we’re going to ban vaping then why aren’t we similarly banning tobacco smoking? Or the chewing of betel nuts? Or the drinking of sugar-loaded fizzy drinks and bubble teas that is making our youths overweight and on a path to type 2 diabetes? Why ban vaping but merely regulate THP?
Any shop that used to sell vaping products can no longer do so even if they don’t contain any nicotine at all. What is the sense in that? How is this going to be controlled? How many people are going to be employed checking that shops don’t have secret “under-the-counter” stashes of vapes? What will happen if they get caught? Will there be the public crushing of vials in the streets, a bit like the smashing of whisky bottles in Prohibition 1920s America? We will soon be witnessing a huge, untaxed and uncontrollable black market blossom beneath our very eyes.
If we don’t know enough about something because we don’t have the evidence then we should not make public policy on a whim. The inconsistencies of the amendments to the THPCA are self-evident and detrimental to people who want to stop smoking. We really should start again - that means ignoring the lobbyists and going back to the first principles of public health policy, which are to balance the risks of banning vs regulating, and be consistent because the population will take advantage of those inconsistencies.
On balance, I believe that making safer alternatives available to smokers so that they can quit far outweighs the risk of hooking new youths into bad habits. And the evidence we have that the dangers of vaping products are less than those of smoking tobacco can’t be ignored and won’t go away.
Wouldn’t it be better to wait for the evidence, and tax these alternative products rather than forcing them underground? Is our National Health Insurance scheme so well-funded that it has the privilege of choosing between tobacco tax and a vaping tax blackhole?
The amendments to the THPCA dealing with tobacco alternatives do not make sense when the legislation is intended to reduce harm and safeguard public health. We can only hope that common sense will eventually prevail and that these amendments will be reversed in the fullness of time.
Lee Faulkner is a Fellow of the Institute and Faculty of Actuaries, the UK’s actuarial body, and has more than 30 years’ experience in the world of financial services in Asia, Europe and Latin America. He is a Taiwan Gold Card holder and now lives in Taipei.