Letter to the Editor

Electronic cigarettes (e-cigarettes) have been the subject of numerous debates in the literature. (Bullen et al., Reference Bullen, Howe, Laugesen, McRobbie, Parag and Williman2013; Cressey, Reference Cressey2014; The Lancet, 2013) So much discussion has been on it this year alone to the extent that the word vape, which means ‘to inhale and exhale the vapour produced by an e-cigarette or similar device’, has become the Oxford Dictionaries Word of the year. E-cigarettes have gained popularity amongst the youth who are smokers and want to quit as well as among children and adult non-smokers who fancy it. (Centers for Disease Control and Prevention, 2013; Dawkins, Turner, Roberts & Soar, Reference Dawkins, Turner, Roberts and Soar2013; Emery, Vera, Huang & Szczypka, Reference Emery, Vera, Huang and Szczypka2014; News & Angeles, n.d.; Serrie, Reference Serrie2014; US Drug and Food Administration, 2014) Even in rural communities in middle- and low-income countries, their availability in shopping centres and through multilevel marketing schemes is common (I.N.S., unpublished observation/data). E-cigarettes are deemed to be safe and effective by their users and their manufacturers; a claim that is scientifically and socially challenged. (Centers for Disease Control and Prevention, 2013; Etter, Reference Etter2014) We hope that this letter would provide a more nuanced understanding of the grey area between ethical and lawful aspects of e-cigarettes’ use, particularly in low- and middle-income countries.

Although there is an ongoing debate whether to legalise e-cigarettes’ sales in some parts of the world (Franchitto, Reference Franchitto2014), we strongly believe that ethical considerations would widen the angle of view on ‘e-cigarettes’. To this date, there is dearth of data on the safety profile of the chemical contents of e-cigarette's vapour. It is already established that nicotine is not the only chemical in the vapour. For instance, one of the many chemical constitutes of e-cigarette cartridge is diethylene glycol (Flouris & Oikonomou, Reference Flouris and Oikonomou2010), which could lead to poisoning and death upon ingestion. (Schep, Slaughter, Temple & Beasley, Reference Schep, Slaughter, Temple and Beasley2009) Hence, arguing the safety of e-cigarettes by showing the proofs of allowable amount of nicotine in them can be easily challenged.

Moreover, it is unethical to purposefully and knowingly ignore the fact that e-cigarettes have put the young non-smoker population at risk of becoming smokers (Serrie, Reference Serrie2014). Our attention needs to be redirected in two distinct trajectories: (1) the long- and short-term clinical implications and (2) the societal repercussions of e-cigarettes’ use particularly in low- and middle-income countries. Gathering longitudinal demographic and health data associated with vaping across population subgroups is very essential, but quite uncommon. We cannot simply wait and witness the – highly doubtful – quitting success of the smokers who choose e-cigarettes over the clinically proven tobacco control strategies at the price of those non-smokers who become smokers by vaping e-cigarettes. This is unethical, unprofessional (from the health professional point of view) and would be detrimental to society and the healthcare systems. The relationship between the tobacco industry and the development of e-cigarettes has been unambiguous (Chapman, Reference Chapman2014).

In our local context, there is a dearth of information and discourse on e-cigarettes and vaping in Malaysia. The current prevalence of smoking in Malaysia is alarmingly high – slightly more than 45%, and there has been less than 2% decrease in the prevalence rate, despite interventions (Lim et al., Reference Lim, Ghazali, Kee, Lim, Chan and Teh2013). High prevalence of smoking, the availability of e-cigarettes and lack of strict regulatory policies on the sales of e-cigarettes and cartridges in Malaysia (‘e-cigarettes not banned but liquid used listed as poison,’n.d.), could impose, as one would speculate, a huge risk to the health of individuals with subsequent detrimental consequences for the Malaysian health system. With the WHO's call on governments to reduce the prevalence of smoking by about 33% by 2,025 (Jha & Peto, Reference Jha and Peto2014), the onus is on the Malaysian government and civil society organisations to take more initiatives that will reduce the prevalence of smoking accordingly. Reliable population data on all forms of smoking will in a large measure guide such initiatives.

E-cigarettes should not be given the benefit of the doubt, when it comes to their speculated efficacy in tobacco control. It is illogical to think of them as possible therapeutic agents in smoking cessation without additional rigorous studies. E-cigarettes should not be possibly considered as a ‘tobacco control strategy’, and should be monitored closely.