MIKAEL ANGELO FRANCISCO
“Never mind the law. The law will come.”
On November 19, 2019, President Rodrigo Duterte declared an immediate ban on the use and importation of e-cigarettes in the Philippines. Delivered in his signature tough-talking demeanor, his proclamation came four days after the country’s first confirmed e-cigarette-associated lung injury (EVALI) case, a 16-year-old girl from Central Visayas.
“I will order law enactment to arrest anybody vaping in public,” promised Duterte, asserting the government’s power to “issue measures to protect public health and public interest.” True to their track record of providing quick and unquestioning support to the chief executive, the country’s law enforcers complied with this directive immediately, arresting vapers in public places the very next day.
A former smoker himself, Duterte has never been shy about his disdain for nicotine products and their detrimental effects on public health. In 2017, he signed Executive Order No. 26, which banned smoking in public and enclosed spaces that are not designated smoking areas (DSAs).
However, while it’s easy to understand why tobacco products would be heavily restricted, Duterte’s strict anti-vaping stance caught many by surprise. After all, e-cigarettes have long been presented as a reduced-harm alternative to actual cigarettes. This left quite a few people wondering: In a country with almost 16 million tobacco-smoking adults as of 2015, why would an allegedly safer substitute be shunned instead of supported?
Duterte’s decree also raised questions on legality. There were multiple reports of police arresting vapers in public places, listing their names in the blotter, and releasing them almost immediately for lack of any actual case to file.
The longstanding positive portrayal of e-cigarettes has given vaping supporters a reason to be skeptical of these recent restrictions. In fact, some e-cigarette users suspected other reasons behind the sudden declaration. “I felt sorry for the government, because it’s obvious that they just want to get some money from the people who use e-cigarettes,” said 23-year-old vaper Lloyd*, a resident of Mandaluyong.
“I was annoyed [when I heard about the ban],” shared Denise*, a 42-year-old e-cigarette user, also from Mandaluyong. “It’s obvious they’d ban something that takes out a chunk of the income they get from the production and sale of tobacco.”
The issue of whether or not e-cigarettes are truly safe and effective cessation devices remains a hotly debated topic. A growing body of scientific evidence, however, is lifting the fog surrounding the vaping discussion—and revealing that, just like with cigarettes more than fifty years ago, the risks of e-cigarette use may have been hiding right under our noses.
A number of bills and laws have come into existence, helping to further define the scope, specifics, and limitations of e-cigarette regulation in the Philippines. Most recently, legislators passed two laws regulating e-cigarettes in the country.
“Republic Act (RA) 11346 bans sale of e-cigarettes to minors below 18 years old and applies the Graphic Health Warning Law on them,” explained Atty. Benedict Nisperos of the public health advocacy group HealthJustice Philippines. Nisperos added that this law, which Duterte signed in July 2019, was the first law that taxed e-cigarettes.
This was further amended by RA 11467, which Duterte signed on January 22, 2020. “RA 11467 increased the tax rates on e-cigarettes and also raised the minimum age of access to 21 years old, banned flavoring in e-cigarettes and reaffirmed the Food and Drug Administration’s authority to regulate these products,” Nisperos expounded. “Thus, the FDA can issue guidelines that will control the proliferation of these products.”
“More recently, there have been various bills filed in Congress to regulate ENDS (electronic nicotine delivery systems) and heated tobacco products (HTPs),” shared Dr. Ulysses Dorotheo, Executive Director of the Southeast Asia Tobacco Control Alliance (SEATCA).
One of these bills, SBN-1183, sought to prohibit the “use, sale, distribution, trade, importation, and marketing of Electronic Nicotine or Electronic Non-Nicotine Delivery Systems (ENDS/ENNDS) in the Philippines until otherwise declared as not harmful,” but has remained pending with the Committee since 2019. Another bill, SBN-1074, pushed for an increase in the excise tax on HTPs, and was eventually consolidated with RA 11467.
Dorotheo also lamented the fact that a number of congresspeople have been pushing to enact legislation to lower the minimum age of access from 21 to 18, “on the basis that they are ‘safer’ alternatives for smokers to cigarettes.”
While there are restrictions on who can access e-cigarettes and where they can use them, the importation of vapor products is still allowed, contrary to Duterte’s initial decree. However, the brands must be properly registered with the FDA.
“There is no ban,” asserted Antonio Israel, president of the Nicotine Consumers Union of the Philippines (NCUP) and of Iloilo-based smokers’ consumer advocacy group ProYosi. “There is no ban on e-cigarettes and HTPs under Executive Order No. 106 (EO 106) signed by President Duterte on February 26, 2020.”
To clarify, while e-cigarettes are not completely banned from the Philippines, EO 106 does, in fact, prohibit the manufacture, distribution, marketing, and sale of unregistered and/or adulterated (weakened or lessened in purity by adding an inferior or foreign substance) electronic nicotine/non-nicotine delivery systems, HTPs, and other novel tobacco products. It also bans vaping in certain public places, while providing for the establishment of DSAs.
Israel also explained that as per RA 11467, vapor products are treated as a separate category from HTPs, and thus has its own respective tax rate.
As for the issue of vaping-related arrests, Israel said that the issuance of EO 106 “has clarified the matter, allowing vapers to use their devices in certain places.”
Nisperos stated that vaping is a public health nuisance, meaning there are applicable provisions in the New Civil Code that can guide law enforcers. In Article 694 of the New Civil Code (NCC) of the Philippines, an “act, omission, establishment, business, condition of property, or anything else” that “injures or endangers the health or safety of others” is considered a nuisance, and can be abated or stopped “without judicial proceedings.”
Other anti-vaping advocates offer a slightly different perspective. “Proper information and health intervention is necessary because in a way, [vapers] are victims of addiction, too,” says Mardy Halcon, the Philippines’ Media Advocacy Coordinator for the non-profit organization Campaign for Tobacco-Free Kids.
Some e-cigarette users and vape shop owners weren’t fazed by the arrests, though. A representative from RJVH Vape Shop in Tarlac opined that the police officers who conducted the arrests were simply doing their jobs. “If you’re a responsible vaper, don’t do it outside your house, period. There will be no violation if no one will violate [the rules].”
In terms of whether or not vaping should be regulated, both pro- and anti-vapers seem to agree that regulations must indeed be put in place.
For countries with weak regulatory frameworks or practices, a ban serves the twofold purpose of being a precautionary measure and limiting widespread access of the products that fall under its scope.
And unsurprisingly, vapers and vaping advocates are opposed to an actual e-cigarette ban.
“Smokers have a right to information and access to better alternative nicotine products than cigarettes,” said Israel. Meanwhile, RJVH’s representative emphasized the lack of scientific proof to justify a total vaping ban. “There are no clear or proven facts [on the negative effects of e-cigarettes] for the government to ban vaping.”
However, the fact that we still don’t have complete information about vaping’s long-term effects is exactly why we need stricter regulations—especially since we’re learning more and more about it with each new study.
“Since there [has yet to be any] long-term scientific evidence on the safety or relative harm of these products relative to cigarettes, such policies should take the precautionary approach to regulation and, if ever, err on the side of caution,” argues Dorotheo.
A quick look at the history of smoking in the United States reveals that it took decades before the world had a fuller picture of tobacco’s harmful effects on health. For a long time, cigarettes were marketed as a “cool” hobby and a symbol of machismo. And when tobacco products were first allowed on the market, there wasn’t enough public health information or experience to prove that a ban was necessary.
By the time the U.S. Surgeon General’s landmark 1964 report was released—an analysis of over 7,000 studies and scholarly articles that established a definitive link between smoking and lung cancer—it had been over 50 years since the popularization of commercial tobacco products in the country.
All of this resulted in what today’s anti-smoking advocates refer to as a global tobacco use pandemic.
“[M]any people thought it was ‘just smoking,’ that it wasn’t harmful, that adults should be allowed to choose to poison themselves if they wished, that the industry could be trusted and should be treated just like any other industry, that the industry and its products can be regulated instead of banned,” said Dorotheo. “See where that line of thinking has led us.”
In contrast, modern e-cigarettes, which were invented in 2003 by Chinese pharmacist Hon Lik and brought to the U.S. market in 2007, have been popular with the public for less than 15 years. And while it’s true that it’s too early to tell if e-cigarettes present the same level of risk as traditional cigarettes, scientific evidence pointing to this is steadily piling up.
“A ban on vaping is, for me, supported by science because early studies into the effects of e-cigarette use show detrimental effects on the lungs, as well as the immune and cardiovascular systems,” said Halcon.
Halcon mentioned that exposure to e-cigarette aerosol has been shown to inhibit healthy lung function, compromise the lungs’ ability to fight infection, and even possibly reduce the function of cardiovascular tissue that controls blood flow. “Although it is too early to draw conclusions on the long-term effects of e-cigarette use, this dysfunction is commonly observed early in the development of cardiovascular disease.”
Nisperos also shared this opinion. “While there is still no firm science to prove the claims of the tobacco and vape industry that these products are less harmful and are effective cessation devices, we should follow the precautionary principle in public health regulations,” he noted. “Just like how building on the consensus that tobacco is deadly, it will take longer years to fully understand the impact of nicotine addiction through vapes to its users.”
Existing and emerging study findings, however, are pointing to some truly frightening trends and associations between vaping and an assortment of diseases—including COVID-19.
On its FAQ page, the World Health Organization (WHO) warns against the risks that come with using ENDS and ENNDS. While it cites the lack of evidence about the relationship between COVID-19 and e-cigarette use, it outright calls e-cigarettes “harmful,” as they have been found to increase the risk of heart disease and lung disorders. Furthermore, WHO also mentions that the hand-to-mouth action of using e-cigarettes may increase the risk of virus transmission and infection.
On the subject of lung damage, research reveals that e-cigarettes can, in fact, do direct damage to lung cells. Specifically, vaping inflicts damage upon macrophages, monocytes, and other immune cells that fight against invading pathogens in the body. Worse, vaping has also been shown to increase the already harmful impact of lung pathogens—in some cases, even worse than if the pathogens had been exposed to cigarette smoke—and cause potentially lung-damaging inflammation.
Additionally, numerous studies have shown that nicotine exposure drives an increased expression of a receptor called ACE-2 on lung cells. It is the same receptor that SARS-CoV-2, the coronavirus that causes COVID-19, attaches to. To replicate, viruses must latch onto a receptor—and with more of a specific type of receptor in the body comes a higher risk of infection.
In other words, vaping can reduce lung function, severely cripple our body’s defenses against COVID-19 and other lung infections, and make lung pathogens even more deadly than they already are.
According to Halcon, a vaping ban in public places could reduce the number of Filipinos who vape, especially among the youth. “My son is a student in a university in Cabuyao, and he often complained last year that vapers are all over the school – some are inside and others are just sitting outside a convenience store just across the university. He finds it very inconvenient when passing the roads because these vapers have no qualms vaping in public. He doesn’t like the smoke and the sight of young people who are slowly getting addicted to vapes.”
“We have not seen the full scale of the impact of nicotine addiction on our youth because these products are just new,” lamented Nisperos, “but they are already so accessible and enticing to them.”
In the United States, a national campaign called Tobacco 21 aims to raise the country’s minimum legal age (MLA) for tobacco and nicotine sales to 21. Data from the United States’ Substance Abuse and Mental Health Services Administration (SAMHSA)’s 2016 National Survey on Drug Use and Health revealed that approximately 95% of adult smokers begin smoking before turning 21—and four out of five turn into regular, daily smokers even before reaching that age.
In comparison, the Philippines’ Global Adult Tobacco Survey (GATS) 2015 revealed that the average age of daily smoking initiation in the country was 17.5 for boys and 18.3 for girls, and that among those surveyed, only 0.8 percent were e-cigarette users at the time of the study.
Perhaps among the most damning pieces of evidence linking vaping to COVID-19 is a recently published study from the United States. Conducted by Stanford University researchers in May 2020, the study involved 4,351 participants aged 13 to 24.
According to the researchers, young people who had used both cigarettes and e-cigarettes within the previous 30 days were nearly five times as likely to demonstrate symptoms of COVID-19 (including coughing, fever, breathing difficulties, and fatigue) as those who used neither. These same “dual users” were also 6.8 times more likely to have COVID-19 than non-users. Similarly, participants who had a history of vaping turned out to be five times more likely to have COVID-19 than non-vapers.
In other words, teenagers and young adults who use e-cigarettes appear to have a much higher chance of getting COVID-19 than those who don’t. (Remember, though, that this study demonstrates correlation, not causation.)
Interestingly, the researchers were unable to find a strong connection between conventional cigarette use and COVID-19 diagnosis. This was mostly attributed to the fact that in various studies, it has been observed that the trend among many young users is to use both cigarettes and e-cigarettes.
But if that’s the case, then one has to wonder: Are e-cigarettes truly effective in helping smokers kick the habit?
Lloyd shared that he started vaping in March 2019 so that he could stop smoking. Similarly, Denise found vaping to be a good substitute for smoking. “I still feel and believe that vaping is way safer than smoking cigarettes,” she shared.
On the other hand, B*, a 41-year-old e-cigarette user from Pasig, got into cigarettes due to peer pressure. “Currently, I’m hooked, but like my previous vice, I [can just] quit, depending on my mood or health condition.”
Sadly, while there are many vapers who claim to have been able to quit smoking through e-cigarette use, there is little evidence to say with certainty that e-cigarettes are, indeed, effective cessation devices. In fact, quite a few pieces of published scientific literature say otherwise.
A decade-long study conducted by researchers from the United Kingdom examined the impact of nicotine replacement therapy (NRT) and e-cigarettes on the cigarette consumption of adults in England aged 16 years and above. Based on data spanning from 2006 to 2016, the researchers concluded: “If use of e-cigarettes and licensed NRT while smoking acted to reduce cigarette consumption in England between 2006 and 2016, the effect was likely very small at a population level.”
Some studies even revealed smokers who, instead of quitting and switching to e-cigarettes, ended up becoming dual users. A 2019 study from South Korea showed that among 59,532 adolescents, approximately 40 percent used cigarettes, e-cigarettes, and HTPs concurrently. The study’s findings also revealed “high polytobacco use and the lack of an association between HTP use and cigarette quit attempts.”
As Dorotheo put it: “Anecdotal evidence of quitting smoking with e-cigs is just that: anecdotal.”
Both B and Denise shared that they actively read and obtain information about e-cigarettes online. For Denise, it’s more about curiosity than anything else; she reads whatever pops up on her feed. B, on the other hand, is more interested in the recreational aspects of it. “I always read, because I want to know updates in other countries about vaping. Mainly about new products, improvements, tips, and best deals.”
When asked about her thoughts on the negative health effects of e-cigarettes, B said that she was “neutral” about it. “I just know it’s safer than smoking cigarettes, unless the information being given to me is backed up by scientific facts.”
An oft-repeated claim, typically presented as scientific fact, is that vaping is “95 percent less harmful” than smoking traditional cigarettes. Sadly, that claim has recently been debunked as “outdated, misleading and invalid” by six public health experts, including the co-director of the Center for the Study of Tobacco Products at Virginia Commonwealth University.
Based on their investigation, the claim originated from a 2014 study that ranked 12 nicotine products based on 14 harm criteria. However, the authors of the study themselves stated that they lacked “hard evidence for the harms of most products on most of the criteria”; furthermore, they acknowledged that “there was no formal criterion for the recruitment of the experts” who participated in the analysis. In addition to that, e-cigarettes have undergone so many changes over the course of the last six years that those observations, even if valid at the time, would no longer apply now.
While this might be a hard pill to swallow, the fact that the “95 percent” claim is invalid cannot and must not be ignored, if all sides involved were to have a true, meaningful discussion on e-cigarette use.
Sifting through the various findings and studies on vaping can be quite overwhelming, especially for the average person with no expertise in science or public health. Thus, when it comes to looking for trustworthy information and studies on vaping, Dorotheo had a few tips to share.
“[First, check] for conflicts of interest and/or past relationships of authors with the tobacco industry. Read the arguments and positions for both ‘pro’ or ‘contra’ sides.” Dorotheo also mentioned looking at the summaries published by Public Health England (which has a generally pro-vaping stance), the United States’ National Academies of Sciences, Engineering, and Medicine (NASEM), the European Respiratory Society, and Australia’s National Health and Medical Research Council, among others.
“WHO is also a reliable source, as it has to sift through the available evidence before developing its position or making policy recommendations.”
As a means of mitigating the spread of the coronavirus during most of the first half of 2020, the national government placed various regions and cities in the Philippines under different states of quarantine. Thus, it’s not surprising that there have hardly been any reports of vaping-related arrests over the last few months, since most people were forced to stay inside their homes.
Recent developments in Philippine e-cigarette legislation have also cleared some of the smoke surrounding where vapers can and can’t use their e-cigarettes, in sharp contrast to the weeks following Duterte’s bold declaration of a public ban.
The COVID-19 pandemic has also had an impact on the e-cigarette use of some vapers. According to Lloyd, being forced to stay at home made him use his e-cigarette more frequently than usual.
Meanwhile, both B and Denise noted an increased difficulty in obtaining e-juice for their e-cigarettes, due to travel restrictions and the fact that some suppliers had difficulty sourcing raw materials because of the pandemic. However, they both managed to find ways around this problem. “Being a regular customer of some vape shops, coordination with the owners allowed us to purchase e-juice online and just get it delivered via courier services,” shared Denise. It’s worth noting that under previous ECQ guidelines, certain courier services allowed only essential items such as food or prescription medicine for delivery jobs.
It’s not surprising that vape shop owners would go to great lengths to accommodate their customers, though, and for reasons other than profit. For RJVH and other vape shops, their primary mission remains helping smokers wean themselves off of cigarettes.
“New customers may be discouraged [by these new regulations], but old or current vapers are not,” said RJVH’s representative. “They know what’s better for their health, and it’s definitely not smoking tobacco. Sales may go down [because of the ban], but I will never give up my advocacy to help smokers quit.”
The recent developments in the country’s e-cigarette regulations have made one thing clear: In terms of the government’s policy-making and implementation strategies, there’s plenty of room for improvement.
Prior to the COVID-19 pandemic, the FDA was already in the process of developing new regulations under the recently amended sin tax law. The Department of Health (DOH) and the FDA have also published regulations on e-cigarettes; however, due to the fact that they’ve been challenged in court by the vaping industry, said regulations have not been implemented.
According to Dorotheo, both the DOH and the Department of Education (DepEd) have been consistent in their public health policy positions and educational campaigns against both smoking and vaping. In addition, a number of LGUs have passed ordinances that prohibit both smoking and vaping in public places.
“Overall,” observed Dorotheo, “these efforts, as with other tobacco control and health promotion efforts, have been limited, and are not yet systematic.”
Without going into specifics, Israel stressed the need for “fair, reasonable, and evidence-based regulations that would encourage current adult smokers who still choose to smoke to switch to better alternatives to cigarettes.”
Meanwhile, those in favor of stricter e-cigarette regulations already have a few ideas in mind. First on their list? A ban on all flavors.
“If the purpose of e-cigarettes, as claimed by its makers, is to help smokers quit, there is no reason why it should be made enticing,” explained Halcon. “The availability of flavors such as melon and chocolates negates this objective, because it makes e-cigarettes more appealing to the youth.” In addition, Halcon also suggested banning the online selling of e-cigarettes.
Both Dorotheo and Halcon said that there should be a ban on e-cigarette advertisements, promotions, and sponsorships; Halcon pointed to the restrictions on tobacco under RA 9211 (or the Tobacco Regulation Act of 2003) as a reference. The two advocates also recommended higher taxes on e-cigarettes. “At present, e-cigarettes are taxed lower than tobacco,” said Halcon, “This gives the public the perception that e-cigarettes are less harmful or not harmful at all, which is not true. “
Dorotheo stated that the legal age of access should be kept at 21 and even increased to 25 for both smoking and vaping. Halcon agreed, citing information from the Philippine Pediatric Society that “the ability of the brain to resist vices happens at 25.” Many of the provisions in RA 9211 indicate that the legal age for tobacco purchase, access, and usage is 18; some vaping advocates say that the legal age in RA 9211 must first be revised from 18 to 21 before they agree to 21 as the legal age for e-cigarette use as well.
Nisperos suggested expanding the scope of what LGUs can do with regard to e-cigarette regulation. “Give power to LGUs to craft their own legislative measures and policies that will regulate e-cigarettes in their locality, making the national standard the minimum.” Back in November 2019, National Capital Region Police Office (NCRPO) chief Major Gen. Debold Sinas urged LGUs in the region to pass ordinances banning the sale of vapes.
Other suggestions from Dorotheo include standardized or plain packaging with large and prominent health warnings, limiting the amount of nicotine in e-juice, maintaining and strengthening the regulatory mandates of the FDA, child-proofing e-juice containers and the electronic devices themselves, and strengthening mass media messaging.
Of course, the ultimate goal is still smoking cessation—and according to Dorotheo, switching from cigarettes to e-cigarettes and other purported cessation devices isn’t really quitting. “Those who shift to vaping [to quit smoking] should eventually quit vaping as well.”
For Dorotheo, there’s only one method of quitting that’s proven to be effective—one that, for some, may require tremendous willpower and determination. “Cold turkey—quitting with only behavioral support and without nicotine replacement—has been the method used by most successful quitters all over the world.”
Dorotheo also noted that while some studies claim that NRT is more successful than straight-up cold turkey quitting, it’s because the study participants could easily tell if they’re receiving placebos or ingesting actual nicotine. Hence, the results are inherently biased.
“Most quitters in the world have not had access to NRT, but still succeeded in quitting,” said Dorotheo, who added that smokers interested in quitting cold turkey may contact the DOH quitline for assistance.
Interestingly, team RJVH agrees. “[E-cigarettes] are helpful if you can’t quit smoking… But if you can quit without vaping, better!”
While there’s still much for us to learn about the full extent of vaping’s effects on the body, one thing is evident: Holding on to longstanding biases regarding e-cigarettes while ignoring what new studies say dangerously feeds the illusion that we’re solving one puffing pandemic—when in fact, we could very well be creating another.
Bitten by the science writing bug, Mikael has years of writing and editorial experience under his belt. As the editor-in-chief of FlipScience, Mikael has sworn to help make science more fun and interesting for geeky readers and casual audiences alike.
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