Dilemma clouds use of e-cigarettes

Vapor devices that deliver nicotine increasingly used in public places

The adoption of a revised tobacco control regulation more than three years ago has left Zhang Jianshu, president of the Beijing Tobacco Control Association, a happy man.

Since the new rule took effect, the number of adult smokers in Beijing has fallen by 200,000, and violations such as smoking in restaurants and bars have become less frequent.

But as more people have stopped smoking in public places, Zhang has a new problem on his hands.

The association has received a growing number of reports and complaints about e-cigarettes being used in public. While law enforcement officers can impose fines on those who smoke traditional cigarettes in such areas, they are virtually powerless to act against those who use e-cigarettes.

"The existing control regulation in Beijing covers only traditional tobacco products that are lighted," Zhang said. "We believe many e-cigarettes are also harmful to smokers and others, and will promote their inclusion in tobacco control law enforcement," he added.

"E-cigarettes are most often used in office buildings, where smoking tobacco is prohibited, according to the reports we received from the public," he said. "People smoking e-cigarettes in offices generally believe they cause no harm to others."

In July, a young woman smoking an e-cigarette while traveling on the subway in Beijing became involved in an argument with several other passengers who tried to stop her. The woman initially refused to do so and said that what she was using was "not a cigarette".

The Beijing Subway Co said there is no rule on whether e-cigarettes can be used on the network, but staff members will try to persuade passengers not to smoke them if they find this is affecting others. The incident involving the young woman triggered heated public debate, with many people calling for legislation to be introduced to control the use of e-cigarettes in public places.

According to the tobacco control regulation adopted in Beijing in 2015, smoking is not allowed in indoor public places, including the subway.

Wang Benjin, former deputy director of the Beijing Health Supervision Bureau, which is in charge of tobacco control law enforcement in the capital, said the bureau's staff members cannot stop people using e-cigarettes, as no such law has been enacted.

"To totally ban e-cigarettes being smoked in indoor public places, the existing tobacco control regulation should first of all be explained or revised by the Beijing People's Congress, the city's top legislative body," Wang said.

According to the World Health Organization, electronic nicotine delivery systems, also known as ENDS, and which include e-cigarettes and vaping, involve risks and are not safe. Toxic substances and contaminants have been found in ENDS aerosols, which can result in a range of pathological changes to the human body, it said.

E-cigarettes use battery-powered cartridges to produce a flavored vapor that often contains nicotine.

Misleading claims

Gauden Galea, the WHO representative in China, said in a statement: "There are only a few studies on the health risks of ENDS. However, there are health risks associated with exposure to nicotine, of inhaling other toxic emissions contained in such products and of inhaling second-hand smoke, particularly among minors, nonsmokers and women who are pregnant."

He added that there is a risk of unintended health consequences from exposure to ENDS, due to the high nicotine concentration in the e-liquids of some of them, and the risks of accidental poisoning and of young people taking up traditional smoking.

"In public places where smoking is prohibited, legislation should apply equally to cigarettes and e-cigarettes in order to protect nonsmokers from deadly exposure to second-hand smoke," he said.

While retailers usually claim e-cigarettes can help smokers to quit, tobacco experts believe this is misleading, and say such products may lure young people to try them, resulting in them habitually smoking.

Jiang Yuan, a tobacco control researcher at the Chinese Center for Disease Control and Prevention, said: "Many e-cigarettes contain nicotine, which is addictive, and cannot be used to quit smoking. Most young people who try e-cigarettes will become addicted to them and this will result in them later smoking tobacco."

Liang Lirong, head of a clinic at Beijing Chaoyang Hospital that aims to help people stop smoking, said there is no reliable evidence to prove the safety of e-cigarettes, and they cannot be used to help smokers to quit.

"We should be alert to the fact that the marketing of e-cigarettes is mainly aimed at young people. Many of those who use e-cigarettes eventually become tobacco smokers," she said.

Some experts believe that e-cigarettes offer a safer alternative, as many of them do not contain tar, the harmful substance that is produced as tobacco burns in traditional cigarettes.

Jiang Hui, director of Peking University Third Hospital's Andrology Department, said he has seen some people buying and using e-cigarettes, as they believe they cause less harm than regular ones.

"For the present, it is better to focus tobacco control on traditional cigarettes, rather than e-cigarettes," he said.

Galea, the WHO representative, said research has not yet conclusively shown whether e-cigarettes can help people to quit smoking.

The WHO is not in a position to recommend ENDS as a way to quit smoking, and urges that smokers who are willing to give up should use proven methods, he said.

China is the largest producer of both traditional cigarettes and e-cigarettes, although most of the latter are exported.

There are no official data on the development, distribution and consumption of e-cigarettes in the country, but according to a report by Guanyantianxia, a consultancy in Beijing, their prevalence is still low, compared with traditional cigarettes, and lower than in many other countries, such as the United States. However, the large Chinese market offers "great potential for the development of the e-cigarette industry", the report said.

E-cigarette sales in China reached 3 billion yuan ($435 million) in 2016, a fourfold increase on the previous year, the report added.

It is estimated that there are between 1.5 and 2 million e-cigarette smokers in the country, which is very low compared with the total number, which exceeds 300 million, the report said.

Of the e-cigarettes produced in China, 90 percent are exported to countries such as the United States, Britain, Poland and Japan, it said.

Citing causes of the significant increase in e-cigarette sales in China, the report said, "In recent years, tobacco control efforts have been intensified... resulting in higher taxes on tobacco and reduced sales of cigarettes, so smokers have begun to turn to e-cigarettes."

Yang Jie, a researcher at the China CDC's Tobacco Control Office, said an e-cigarette is not considered a drug or an electronic product, which has caused "a dilemma" over effective supervision.

Galea said that although the consumption and prevalence of e-cigarettes is low, the industry has intensified marketing efforts focused on young people, which may lead to an increase in their use in the future. "Because of a lack of regulation covering production, marketing and sales, effectively anyone can buy e-cigarettes online at any time, and of unknown quality," he said.

Market targeted

Data from a survey conducted by the China CDC show that about 3 percent of adults have tried e-cigarettes, but only 0.5 percent now use them.

Galea said the country's tobacco industry has been eyeing the e-cigarette market and is preparing to enter it fully.

In 2008, the Zhengzhou Tobacco Research Institute in Zhengzhou, capital of Henan province, obtained the patent for smokeless e-cigarettes.

In July 2016, China Tobacco Yunnan Industrial Co in Southwest China's Yunnan province, started production of e-cigarettes.

Galea said the report of the 2018 National Tobacco Work Conference said it is necessary to promote the research of e-cigarettes, and to strive for the approval of national standards covering them.

He said the tobacco industry has also called for the regulation of e-cigarette sales, and has suggested this should be administered by the tobacco monopoly administration.

Some tobacco control advocates have called into question the industry's use of e-cigarettes to normalize smoking behavior, foster and initiate new smokers, prevent smokers from quitting, or stopping them from using other effective cessation methods, Galea said.

In China, there are no regulations covering the production, manufacturing standards and oversight of e-cigarettes. There is also a lack of regulation on accessing and consuming them, apart from a ban on sales to minors introduced in August.

According to a circular jointly released by the State Administration of Market Regulation and the State monopoly China Tobacco, e-cigarettes sold on the market vary in quality, and some may pose safety risks such as liquid leakages or use of substandard batteries.

It said the core material for most e-cigarettes is nicotine, which can cause damage to the respiratory system.

In Hangzhou, capital of Zhejiang province, e-cigarettes will be covered by a new tobacco control regulation that will take effect on Jan 1, making it the first city on the Chinese mainland to include them in such legislation. This means that those who smoke e-cigarettes in most indoor public places in the city will be liable to fines of up to 200 yuan, the same as those for smokers of traditional cigarettes.

Galea said the measures introduced to ban the sale and distribution of e-cigarettes to minors should be emphasized. To deter their use in this age group, he said they should be taxed at a level that makes such products and e-liquids unaffordable to the younger generation.

The authorities should also ban or restrict advertising, promotion and sponsorship of e-cigarettes, and require warnings to be posted about the potential health risks surrounding their use, he said.

"Where there are laws prohibiting the smoking of tobacco products, they should also apply to the use of e-cigarettes," Galea said.