Smoke from combustion is the primary reason for harmful constituents in cigarettes as it generates thousands of chemicals and solid particles that are linked to various health issues.
Reassessing accessibility to ensure effective tobacco control methods and policies
ACCORDING to the Global Adult Tobacco Survey (GATS) Malaysia 2023, the number of e-cigarette users in Malaysia has increased dramatically over the past 12 years.
The prevalence of e-cigarette use among those aged 15-24 increased from 1.1% in 2011 to 8.6% in 2023, representing a 600% rise.
Meanwhile, the overall rate of e-cigarette use in the country has also surged, going from 0.8% in 2011 to 5.8% in 2023 - more than a six-fold increase.
The survey found that 68.1% of Malaysian adults are aware of e-cigarettes, and 8.9% (10.5% of men, 0.8% of women) have used them.
This uptake could be due to inadequate information regarding vapes, e-cigarettes and other alternative tobacco products – how they are distinct and why they should be regulated accordingly.
What’s in aerosols?
While smoke is technically an aerosol, not all aerosols are created equal.
Smoke is a complex mixture of solid particles and thousands of chemicals generated at high temperatures when a material burns.
By contrast, an aerosol formed at lower temperatures through vaporisation and condensation is much simpler and contains far fewer harmful chemicals.
This also means that e-cigarettes do not use tobacco - they vaporise an e-liquid solution containing nicotine and flavours when used.
Since there is no burning involved, neither heat-not-burn products nor vapes produce ash or smoke. Instead, they use heating systems to generate an aerosol inhaled by users, classifying heated tobacco products and vapes as “smoke-free” alternatives.
Based on Philip Morris International’s (PMI) research, heated tobacco products’ (HTP) aerosol contains significantly fewer harmful chemicals compared to cigarette smoke—a claim supported by both targeted and untargeted analyses conducted by the company.
These additional compounds are likely attributed to the flavour system used in HTPs. A toxicological evaluation concluded that these additional compounds do not pose any additional hazard compared to cigarette smoke [1].
PMI Project Management and Knowledge Integration manager Mark Bentley highlighted the significant differences between the two, emphasising the reduced presence of harmful chemicals in heated tobacco aerosol.
From the list of more than 100 harmful and potential harmful constituents (HPHCs), various governments and regulatory bodies have compiled priority lists of toxicants that require measurement in cigarette smoke. The most comprehensive list is by the [United States] Food and Drug Administration (FDA) and their list of 93 constituents.
“PMI has analysed, using targeted methods, the concentrations of these 93 constituents in cigarette smoke versus heated tobacco aerosol.
“The results showed a 90-95% reduction for these constituents in heated tobacco aerosol compared to cigarette smoke. This reduction aligns with the findings of other independent studies,” he said.
While HTP aerosol contains significantly lower levels of harmful chemicals compared to cigarette smoke, it is important to remember that it is not risk-free.
Exposure from alternatives
For one, PMI had conducted a passive exposure study in Japan to assess the impact of tobacco heating systems (THS) use in real-life settings on users and non-users.
PMI Regional Scientific Engagement Asia director Tomoko Iida stated that, “this study exposed non-smokers to THS aerosol in a restaurant in Tokyo”, with the results showing that the use of THS didn’t generate environmental smoke and had no adverse effects on indoor air quality [2].
“Also, non-smokers didn’t have an increase in exposure to nicotine and tobacco-specific nitrosamines (TSNA) as a result of passive exposure to the THS aerosol,” she said.
In tandem, Japan’s Health Ministry had also conducted its own studies and concluded that the “results do not negate the inclusion of HTPs within a regulatory framework for indoor tolerable use from exposure to HTP aerosol, unlike cigarette smoke”.
In a reduced emission study published in the Journal of UOEH—the National Institute of Public Health (NIPH) of Japan—concluded that “the concentrations of nicotine in tobacco fillers and the mainstream smoke of IQOS were almost the same as those of conventional combustion cigarettes, while the concentration of TSNAs was one fifth with carbon monoxide one hundredth that of conventional combustion cigarettes.
Concerns on accessibility
The GATS Malaysia 2023 survey also revealed that smoking cessation behaviours and healthcare utilisation among smokers have remained stagnant over the past year.
This suggests that while e-cigarette use is rising rapidly, efforts to help people quit smoking more broadly have seen limited progress.
Research by Public Health England demonstrated the importance of providing accessible and affordable cessation support and services to help smokers quit.
These include evidence-based interventions such as counselling, nicotine replacement therapy (NRT) and quitline services. Public awareness campaigns and educational initiatives also play a crucial role in promoting the availability and effectiveness of these resources.
Importantly, those aiming to switch to less harmful alternatives or quit need to ensure adequate access to and use of NRT, as inadequate nicotine replacement or premature discontinuation are both linked to a higher likelihood of relapsing to smoking [3].
While current tobacco regulations restrict the sale of cigarettes and other tobacco products to individuals under age 18, e-cigarettes and vape products containing nicotine remain readily accessible to minors.
This accessibility is a growing concern due to the removal of liquid nicotine from the Poisons Act 1952, which was intended to enable taxation on e-liquids with nicotine but inadvertently opened a loophole for unrestricted sales.
It is crucial to address this regulatory gap and implement measures to restrict the sale of nicotine-containing products to individuals under the legal age.
This can be achieved through various strategies, such as:
> Enacting legislation that specifically prohibits the sale of nicotine-containing products to minors.
> Implementing age verification systems at points-of-sale.
> Raising awareness about the potential risks of tobacco products among youth and parents.
While these products demonstrate significant reductions in harmful chemicals compared to cigarette smoke, it remains important to address issues of accessibility to minors and implement robust regulations to safeguard public health.
By leveraging research findings and raising public awareness about the harm of tobacco use, these strategies have proven effective in reducing smoking rates, preventing initiation, and protecting public health.
Continued research, evaluation, and implementation of evidence-based tobacco control strategies are essential to further progress in reducing the burden of tobacco-related diseases.
References:
1. What do we know about the chemistry of IQOS aerosol?: https://www.pmiscience.com/en/news-events/open-science/september-open-science-presentations/bentley-chemistry-iqos-aerosol/
2. The story of THS in Japan, an interview with Tomoko Iida: https://www.pmiscience.com/en/news-events/scientific-update-magazine/the-story-of-ths-in-japan--an-interview-with-tomoko-iida-/
3. Health matters: stopping smoking – what works?: https://www.gov.uk/government/publications/health-matters-stopping-smoking-what-works/health-matters-stopping-smoking-what-works
