Thursday 4 April 2019

Don't just sit there and let Hong Kong ban vaping

In February, the government of Hong Kong announced the prohibition of e-cigarettes and heat-not-burn tobacco products. As CNN reports...

Under the sweeping draft law, which begins its path through the legislature on February 20, anyone who imports, makes, sells or promotes new smoking products could face six months in jail or a HK$50,000 ($6,370) fine.

Imagine jailing people for helping someone give up smoking. Imagine thinking that prohibition works. This is an incredibly stupid and harmful idea. I'm particularly annoyed by it because I would like to visit Hong Kong one day.

But it's not a done deal yet. The government has launched a public consultation and anyone can respond. You can read the text of the bill here and you can give them your thoughts by uploading a Word document or PDF here. Alternatively, you can e-mail them at

The consultation ends on Monday so make haste. Please be polite.

This is what I sent them...

The proposal to ban the sale of e-cigarettes and heated tobacco products in Hong Kong runs contrary to the Legislative Council's stated desire to 'discourage smoking, contain the proliferation of tobacco use and minimise the impact of passive smoking on the public'. It is based on a number of discredited myths about tobacco harm reduction and will deprive smokers of the most effective option for quitting while forcing vapers to either return to smoking or purchase on the black market.

In the UK, which has one of the highest rates of vaping in the world, there has been much research into tobacco harm reduction. Health authorities, including Public Health England and the Royal Society of Physicians, have concluded that the risks of vaping are unlikely to exceed five per cent of the risks of smoking. E-cigarettes have been on the market for a decade and I am unaware of a single person contracting a disease or dying as a result.

Regular vaping among never-smokers is relatively rare and recent research has confirmed that vaping does not act a 'gateway' to smoking. Although some anti-vaping academics have published and promoted studies which purport to show a gateway effect, they disregard an obvious explanation for their findings. In any society in which tobacco is available there will always be a proportion of young people who smoke. Moreover, some young people are more inclined to experiment with nicotine than others. It would be truly amazing if not a single young person who had tried vaping, even once, went on to smoke. No advocate of tobacco harm reduction claims that one puff on an e-cigarette inoculates every individual from the desire to ever smoke. The question is whether that person would have smoked if he had never vaped (probably) and whether youth smoking rates have risen in societies where large numbers of young people vape (they have not).

After vaping became popular in 2012, England's smoking rate fell by 20 per cent in just five years, following five years in which the rate had been almost flat. In the same period, the smoking rate among children halved and is now at the lowest rate on record. Vaping is not a gateway to smoking, it is a gateway from smoking (as I can personally attest).

The Legislative Council claims that there is 'a lack of sufficient evidence to prove that these products can help quit smoking'. This is highly contestable. In fact, there is plenty of convincing research showing that e-cigarettes are effective as a long term substitute for conventional cigarettes. For example, a recent study published in the New England Journal of Medicine found that smokers who used e-cigarettes were more than twice as likely to quit than those who used nicotine replacement therapy. 

A study from the USA found that e-cigarette users were 73 per cent more likely to succeed in giving up smoking than would-be quitters who do not vape. Even with the cruder first generation products, randomised controlled trials found that smokers were twice as likely to quit if they vaped than if they were given a placebo (see Bullen et al. 2013 and Caponnetto et al. 2013).

A study of vape shop customers found that 41 per cent had quit smoking within a year of taking up e-cigarettes and a clinical trial using second generation e-cigarettes saw 53 per cent of subjects quit smoking. Perhaps most impressively, vaping leads to cessation even among smokers who had no intention of quitting at the outset (see Polosa et al. 2011 and Caponnetto et al. 2013b).

The Legislative Council claims that 'all these new smoking products are harmful to health and produce second-hand smoke'. E-cigarettes do not produce secondhand smoke because they do not produce smoke at all. They produce vapour. Compelling evidence of harm from e-cigarette vapour is lacking and there is certainly no evidence of harm from secondhand vapour. In any case, the argument for encouraging e-cigarette use in harm reduction does not require e-cigarettes to be entirely harmless. It only requires them to be significantly less harmful. 

The Legislative Council is concerned that '[t]he public may underestimate the harmful effects of these products'. This seems unlikely given how many unfounded scare stories have been published in recent years. A recent study from the USA found that the number of people who over-estimate the risks of vaping (ie. who believe that it is as harmful as smoking) has risen sharply since 2012. Public health authorities should be tackling this kind of ignorance rather than encouraging it. Creating an environment in which the most dangerous nicotine delivery devices are legal while the least dangerous are prohibited sends an anti-science message to the public.

The Legislative Council also notes that 'there are studies that suggested that the introduction of these new products could result in dual use with conventional cigarettes'. It is true that not all smokers quit immediately when they start using e-cigarettes, but 'dual use' represents the start of a journey towards abstinence from cigarettes for a great many of them. Many people who use nicotine patches or nicotine gum are also 'dual users'.

It is unfortunate that the Legislative Council's brief rehearses many of the 'zombie arguments' made against e-cigarettes almost a decade ago. Some of these objections were worth raising when vaping was in its infancy, but scientific research and real world experience has revealed them to be unfounded. The best evidence suggests that the health risks of vaping are trivial in comparison with the risks of smoking. The vast majority of vapers are ex-smokers, many of whom would still be smoking if they had not discovered e-cigarettes. There is no 'gateway effect' in any meaningful sense and there is no risk from 'secondhand vapour'.

Heat-not-burn products have only recently become popular, but the early evidence points in the same direction. In 2017, the UK's Committee on Toxicity concluded that there is 'a likely reduction in risk for smokers deciding to use heat-not-burn tobacco products compared with continuing to smoke cigarettes'. A sharp decline in cigarette sales in Japan after iQOS became popular there further indicates the potential  of these products in tobacco harm reduction.

Five years ago, a number of European Union countries had a de facto or de jure prohibition on the sale of e-cigarettes. Today, e-cigarettes are legal to buy, sell and use in all of them. Various other countries, such as Switzerland, Norway, New Zealand and the United Arab Emirates, have recently legalised - or are in the process of legalising - e-cigarettes. From the perspective of public health, personal liberty and free markets, it would be regrettable if Hong Kong went in the opposite direction.

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