FAQs on E-Cigarettes, Vaporisers and Heat-Not-Burn Tobacco Products

FREQUENTLY ASKED QUESTIONS ON E-CIGARETTES, VAPORISERS AND HEAT-NOT-BURN TOBACCO PRODUCTS 

Singapore has banned the importation, sale, distribution for sale, possession, use and purchase of emerging and imitation tobacco products to protect our population from the known and unknown health risks of such products. These products include e-cigarettes and other types of vaporisers [also known as Electronic Nicotine Delivery Systems (ENDS)], and heated tobacco products.   

1. Concerns on potential gateway effect

        E-cigarettes and vaporisers may cause non-smokers, particularly youths, to become addicted to nicotine, and serve as a gateway to experimentation and regular use of cigarettes later on.

        There is evidence that e-cigarette use in non-smokers is associated with future cigarette smoking.

        The United States (US) Surgeon General reported that e-cigarette use is strongly associated with the use of cigarettes among youths and young adults[1]. This is supported by a systematic review of nine studies involving more than 16,000 youths in the US which found that e-cigarette users were three times more likely to become cigarette smokers as compared to non-users[2]. Most recently, the US National Academy of Sciences, Engineering and Medicine conducted an analysis of all existing scientific evidence relating to e-cigarettes and concluded that there is substantial evidence that e-cigarette use increases risk of ever using regular cigarettes among youths and young adults[3].

        In the United Kingdom, a study involving 2,836 adolescents found that people who used e-cigarettes were four times more likely to have started smoking 12 months later[4]. Other studies in Canada and Poland similarly support this gateway effect.

2. E-cigarettes and vaporisers are inherently harmful

        E-cigarettes may expose users to chemicals and toxins at levels that have the potential to cause adverse health effects. There is growing evidence to suggest that the long-term inhalation of flavourings used in most e-liquids is likely to pose a risk to health. The long term safety of their use also remains unclear. What is clear is that vapour from e-cigarettes contain nicotine, fine particulate matter (PM2.5), cancer-causing agents, toxic chemicals, and toxic metal nanoparticles, all of which are harmful to health.

        Nicotine is a highly addictive stimulant drug. Short-term effects of nicotine exposure include increased breathing rate, increased heart rate, increased blood pressure and, in more extreme cases, sweating, nausea and diarrhoea. Nicotine exposure also primes users to the use of other addictive drugs. The long-term use of nicotine has been linked to harmful effects on the development of unborn babies as well as on adolescent brain function and development. In addition, nicotine has been found to promote the growth of cancers and cause resistance to cancer treatment drugs[5]. 

3. There is insufficient evidence that e-cigarettes can aid smoking cessation

        There is currently insufficient evidence to conclude whether e-cigarettes can assist smokers to quit.

        The World Health Organization (WHO) does not recognise e-cigarettes as a legitimate cessation aid as there is no conclusive scientific evidence proving the products’ safety and efficacy. The US Food and Drug Administration (FDA) has also not approved the use of e-cigarettes as a therapeutic aid for smoking cessation. To date, there has not been any application to Singapore’s Health Sciences Authority (HSA) to register e-cigarettes as a therapeutic product for smoking cessation.

        The Ministry of Health (MOH) will continue to review new evidence on the safety and efficacy of e-cigarettes for smoking cessation.

4. E-cigarettes have the ability to become entrenched in Singapore.

        Unlike cigarettes which are entrenched tobacco products globally and in Singapore, use of e-cigarettes and vaporisers has not been high in Singapore.

        The promotion of e-cigarettes to the young has resulted in an exponential increase in the number of young people using e-cigarettes in other countries. For example, in the US, past 30-day use of e-cigarettes increased by nine- to ten-fold between 2011 to 2015 among middle and high school students.

        Similar trends of e-cigarette use could occur in our youths and there is a need to prevent e-cigarettes from becoming entrenched in Singapore, given the evidence that e-cigarette use in young non-smokers is associated with future experimentation and use of cigarettes, and the inherent harmfulness of e-cigarettes. No country that allowed e-cigarettes to enter the market as consumer products has managed to restrict the access to only smokers.

A.    E-CIGARETTES AND VAPORISERS

1.    What are e-cigarettes and vaporisers?

Electronic cigarettes (or e-cigarettes) and other types of vaporisers are sometimes also known as Electronic Nicotine Delivery Systems (ENDS). These battery-operated devices heat a solution, or e-liquid, to produce a nicotine-containing vapour which is then inhaled by the user.

Vaporisers can come in many shapes and sizes, and some may not even resemble cigarettes. E-cigarettes and vaporisers can also be used with e-liquids that do not contain nicotine. However, the act of vaping itself mimics smoking.

(Image from: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/index.htm)

2.    What do e-liquids contain, and are these ingredients harmful?

The ingredients of e-liquids vary, but many of the e-liquids used contain nicotine, an addictive and harmful stimulant. Other ingredients generally include propylene glycol, glycerin, water, and flavouring agents.

3.    What is nicotine and why is it harmful?

Nicotine is a highly addictive substance. In fact, according to the US Surgeon General Report (2010), nicotine is as addictive as cocaine or heroin. It is the reason why people find it so difficult to quit smoking, despite knowing about the harms of smoking.

As nicotine is a stimulant, short-term effects of nicotine exposure include increased breathing rate, increased heart rate, increased blood pressure and, in more extreme cases, sweating, nausea and diarrhoea. The long-term use of nicotine has been linked to harmful effects on the development of unborn babies as well as on adolescent brain function and development. In addition, nicotine has been found to promote the growth of cancers and cause resistance to cancer treatment drugs[6].

There is also a risk of nicotine poisoning through the use of e-cigarettes and vaporisers as e-liquids have unregulated levels of nicotine. Some symptoms of nicotine poisoning include dizziness, nausea, vomiting, abdominal pain, diarrhoea, slowing of the heart and breathing rate.

Nicotine is also associated with insulin resistance (or prediabetes), which increases the risk for type 2 diabetes[7].

4.       If the e-liquid does not contain nicotine, would e-cigarettes and vaporisers be safe to use?

Even without nicotine, the vapour from e-cigarettes and vaporisers contains substances that are harmful to health. These include fine particulate matter (PM2.5), cancer-causing agents such as carbonyls and volatile organic compounds, and toxic chemicals and metal nanoparticles such as nickel, tin and lead derived from the e-cigarette or vaporiser device itself  [8]. E-cigarette use thus increases airborne concentrations of PM2.5 and nicotine in indoor environments compared with background levels.

Although some people argue that vapour from e-cigarettes and vaporisers do not contain the same harmful chemicals found in smoke from regular cigarettes, exposure to vapour from e-cigarettes and vaporisers is still harmful to health.

There is currently no data on the long-term safety of using e-cigarettes and vaporisers. However, recent evidence has linked e-cigarette use to lung inflammation[9]. It has been reported that up to 40% of particles emitted by an electronic cigarette can deposit in the deepest areas of youth lungs, and that chemicals contained in these particles may irritate airways or worsen pre-existing respiratory conditions such as asthma and bronchitis.[10] The US National Academy of Sciences, Engineering and Medicine also concluded in their report that vapour from e-cigarettes can induce acute endothelial cell dysfunction, and can promote formation of reactive oxygen species and induce oxidative stress which may lead to tissue injury and disease[11].

In addition, some e-liquids make use of flavouring agents. While the safety of these flavouring agents remain unclear, researchers have detected the presence of diacetyl, a compound that has been associated with lung disease, in 47 out of 51 unique flavours tested[12].

Besides the impact on health, e-cigarettes are also potential fire hazards and may result in injuries. There has been a growing number of cases of e-cigarettes exploding and catching fire.

5.     Can e-cigarettes help smokers to quit smoking?

The most recent Cochrane Review (which systematically reviews the current evidence from randomised controlled trials) published in 2016 has found that the overall quality of evidence that e-cigarettes are a safe and effective way to help smokers quit smoking is low[13]. Another systematic review which looked at 38 studies (20 studies with control groups, 15 cohort studies, three cross-sectional studies, and two clinical trials) found that the odds of quitting cigarette smoking were 28% lower in those who used e-cigarettes compared with those who did not use e-cigarettes. Association of e-cigarette use with quitting did not significantly differ among studies of all smokers using e-cigarettes (irrespective of interest in quitting cigarette-smoking) compared with studies of only smokers interested in cigarette cessation.[14]

Similarly, the US National Academy of Sciences, Engineering and Medicine concluded that there is limited evidence that e-cigarettes are effective at promoting smoking cessation. Although they also conclude from observational studies that there is moderate evidence that more frequent use of e-cigarettes is associated with increased likelihood of cessation.

If the products are not effective as cessation aids, smokers using them to assist in quitting tobacco use may fail and thus maintain a tobacco addiction that might have been broken if other proven quitting methods were used.

Many smokers who use e-cigarettes fail to quit smoking, and end up using e-cigarettes alongside cigarettes; in particular, e-cigarettes may be used in places where smoking is banned. Such dual use maintains the smoker’s nicotine addiction and is a barrier to quitting smoking. It also exposes the smoker to the harms of both smoking and e-cigarettes.

In Singapore, nicotine replacement therapy (NRT) products such as nicotine patches and gum have to undergo stringent evaluation for them to be registered under the Health Products Act (HPA). Manufacturers must show strong and robust evidence on the safety and efficacy of such products for smoking cessation for them to qualify as NRT. Registered products would also be required to be manufactured in accordance with Good Manufacturing Practice and comply with relevant international quality standards. If there are credible long-term scientific studies which support that a particular e-cigarette product is safe and effective for smoking cessation, the Health Sciences Authority (HSA) will consider registering it under the HPA as a smoking cessation product.

Advice and support on smoking cessation are available through the toll-free Quitline at 1800 438 2000 or the iQuit club at www.hpb.gov.sg/iquit.

6.    Are e-cigarettes legal to use in Singapore?

The importation, distribution, sale, purchase, use and possession of emerging and imitation tobacco products such as e-cigarettes and other types of vaporisers, and e-liquids are prohibited under the Tobacco (Control of Advertisements and Sale) Act, or TCASA.

More information about the commencement of the TCASA Amendment Act can be found at:

https://www.moh.gov.sg/content/moh_web/home/pressRoom/pressRoomItemRelease/2018/commencement-of-the-tobacco--control-of-advertisements-and-sale-.html

7.    Are e-cigarettes banned because Singapore cannot tax it?

No, the Singapore Government is able to tax e-cigarettes should we wish to. E-cigarettes are already being taxed in countries including Italy, Portugal, Romania, Slovenia, Latvia, Hungary, Finland, Greece, Croatia and Republic of Korea. Several states in the United States such as Chicago, Minnesota and California have also introduced taxes on e-cigarettes.

B.    HEAT-NOT-BURN TOBACCO PRODUCTS

1.    What is a heat-not-burn tobacco product?

Heat-not-burn (HNB) tobacco products are battery-operated devices that heat tobacco up to a temperature of 350°C. This produces an aerosol containing nicotine and other chemicals, which are inhaled by the user through the mouth and taken into the body. Their main difference from regular cigarettes is that they heat, rather than burn tobacco (a process known as combustion which occurs at a temperature of 600°C). However, both HNB tobacco products and regular cigarettes contain nicotine which makes them highly addictive. 

2.    Are heat-not-burn tobacco products safer than regular cigarette?

HNB products are new tobacco products. As such, there is currently no evidence on their long term safety. The WHO’s stand is that all forms of tobacco use are harmful, including HNB tobacco products[15]. Besides safety, MOH has the same concerns of entrenchment and gateway effect for HNB tobacco products, as for e-cigarettes.

There is no evidence that such products can help people to quit smoking. While there are some industry-funded studies which claim that there are significant reductions in the formation of and exposure to harmful constituents relative to regular cigarettes, there is currently no evidence that reduced exposure to these chemicals translates to reduced harm. 

3.    Are heat-not-burn tobacco products legal to be used in Singapore?

No. Similar to e-cigarettes and vaporisers, HNB tobacco products are considered emerging tobacco products and their importation, distribution, sale, purchase, use and possession are prohibited under the Tobacco (Control of Advertisement and Sale) Act.

[1] U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young Adults. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2016.

[2] Soneji, S. et al. (2017). Association Between Initial Use of e-Cigarettes and Subsequent Cigarette Smoking Among Adolescents and Young Adults. JAMA Pediatrics, 171(8), p.788.

[3] National Academies of Sciences, Engineering, and Medicine. 2018. Public health consequences of e-cigarettes. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/24952.

[4] Conner M, Grogan S, Simms-Ellis R, et al. Do electronic cigarettes increase cigarette smoking in UK adolescents? Evidence from a 12-month prospective study. Tobacco Control Published Online First: 17 August 2017. doi: 10.1136/tobaccocontrol-2016-053539

[5] Chaturvedi, P et al. (2015). Harmful effects of nicotine. Indian Journal of Medical and Paediatric Oncology, 36(1), p.24.

[6] Chaturvedi, P et al. (2015). Harmful effects of nicotine. Indian Journal of Medical and Paediatric Oncology, 36(1), p.24.

[7] Bajaj, M. (2012). Nicotine and Insulin Resistance: When the Smoke Clears. Diabetes, 61(12), pp.3078-3080.

[8] Grana, R. et al. (2014). E-Cigarettes: A Scientific Review. Circulation, 129(19), pp.1972-1986.

[9] Shields, P., Berman, M., Brasky, T., Freudenheim, J., Mathe, E., McElroy, J., Song, M. and Wewers, M. (2017). A Review of Pulmonary Toxicity of Electronic Cigarettes in the Context of Smoking: A Focus on Inflammation. Cancer Epidemiology Biomarkers & Prevention, 26(8), pp.1175-1191.

[10] RTI International. Electronic cigarettes may cause, worsen respiratory diseases, among youth, study finds. New York, NY: RTI International; 2014 Apr 29.

[11] National Academies of Sciences, Engineering, and Medicine. 2018. Public health consequences of e-cigarettes. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/24952.

[12] Allen JG, Flanigan SS, LeBlanc M, Vallarino J, MacNaughton P, Stewart JH, Christiani DC. 2016. Flavoring chemicals in e-cigarettes: diacetyl, 2,3-pentanedione, and acetoin in a sample of 51 products, including fruit-, candy-, and cocktail-flavored e-cigarettes. Environ Health Perspect 124:733–

[13] Hartmann-Boyce J et al. (2016). Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews 2016, Issue 9. Art. No.: CD010216.

[14] Kalkhoran, S., & Glantz, S. A. (2016). E-cigarettes and smoking cessation in real-world and clinical settings: a systematic review and meta-analysis. The Lancet. Respiratory Medicine, 4(2), 116–128. http://doi.org/10.1016/S2213-2600(15)00521-4

[15] WHO Heat-Not-Burn tobacco products information sheet

Last updated on 26 Jan 2018