Dear Mrs. Lam,
We write to you out of concern regarding the proposed complete ban on e-cigarette, heated tobacco products and other reduced risk tobacco product sales. We can find no credible evidence that suggests this ban will meet its stated objective, and its proponents have not presented any, either. On the contrary, a policy of denying smokers access to much safer products and new ways to quit smoking carries obvious dangers that have not been recognized. We cannot see any ethical or scientific reason why a government would ban products with much lower risk than cigarettes, while cigarettes remain available everywhere in Hong Kong. There is no justification for denying smokers who cannot or do not want to quit the option to switch to a much lower risk product. In fact, it is a form of regulation that is likely to have harmful, unintended consequences – more smoking – that will almost certainly kill Hong Kong citizens.
Over the last several years Hong Kong has seen a decrease the prevalence of smoking among its residents, from 11.1 percent in 2010 to 10 percent in 2017. Of particular note is the decrease in smoking rates among those who are 20-‐29, with a decrease from 9.7 percent to 6.7 percent in 2010 to 2017, and those who are 30-‐39, with a decrease from 14.4 percent to 11.2 percent in 2010 to 20171.
Unfortunately smoking rates among males are still quite high at 18 percent. However when age is taken into account, there is better news. In 2010, 15 percent of males aged 20-‐29 and 25 percent of males aged 30-‐29 smoked. The prevalence of smoking among these populations fell in 2017 to 11.6 percent and 19.2 percent, respectively.
Interestingly, a 2016 report shows that, in Hong Kong, ever use of e-cigarettes is highest among males, young adults and current smokers and that quitting smoking is in the top three reasons of why e-cigarettes are attractive. Together these data indicate that it is likely that e-cigarettes are replacing smoking in populations that currently smoke and have the most potential to displace smoking in younger male populations.
We urge the Hong Kong Legislative Council to consider that harm reduction policies can work alongside prevention and cessation programs to reduce the health and economic burden associated with combustible cigarettes. In the WHO FCTC (Article 1d), the definition of ‘tobacco control’ recognizes harm reduction as an integral component.
Alternative nicotine delivery systems (ANDS) are unquestionably much less harmful than combustible cigarettes. In its comprehensive report, Public Health England stated that e-cigarettes are unlikely to exceed 5 percent of the risk associated with combustible cigarettes; the American Cancer Society has conceded that vaping is better than smoking cigarettes; and both the National Academies of Science, Engineering and Medicine and the FDA have recognized nicotine products exist on a continuum of risk, with e-cigarettes, Snus and heat-‐not-‐burn technologies at the lower end near traditional nicotine replacement therapies, and combustible cigarettes at the highest end of the risk spectrum. Recognition that these products present a reduced risk is because they doesn’t employ the traditional cigarette combustion process that releases 7,000 chemicals – some of which are highly carcinogenic – the FDA commissioner Scott Gottlieb has made reduced-risk products like e-cigarettes central to the FDAs roadmap6.
While it’s the addiction to nicotine that keeps people smoking, it’s primarily the combustion, which releases thousands of harmful constituents into the body at dangerous levels that kills people. This fact represents both the biggest challenge to curtailing cigarette addiction ‒ and also holds the seeds of an opportunity that’s a central construct for our actions. E-cigarettes may present an important opportunity for adult smokers to transition off combustible tobacco products.
ANDS have quickly become the number one quit tool in many parts of the world, allowing an untold number of smokers to cigarettes. Economic modeling has suggested that e-cigarettes are contributing to a more rapid decline in smoking rates than were seen in previous years. In the United States and United Kingdom e-cigarettes have outpaced traditional quit methods (Varenicline, nicotine replacement therapies or counseling) and with a higher degree of success.
Snus use in Sweden is considered to be the primary reason that daily smoking prevalence is below 5 percent, making Sweden a “non-‐smoking” country by many public health bodies. This is in sharp contrast to the smoking prevalence rate in the rest of the EU (26 percent) where Snus is banned.
Perhaps most interesting is the decrease in smoking prevalence is highest in males, who have an estimated smoking prevalence of between 2-‐5 percent as of 2018 and prevalence of Snus use of approximately 20 percent9. Finally, heat-‐not-‐burn technology has contributed to a dramatic decline in cigarette consumption in Japan. Cigarette volumes in Japan have fallen by 27 percent in two years, from
43.6 billion sticks in Jan-‐March 2016 to 31.8 billion sticks in Jan-‐March 2018. Analysts at Citi Group attribute the disruption of the cigarette market to heated tobacco products1.
The importance of this cannot be overstated. Policy that encourages smokers to switch to e-cigarettes if they cannot quit or do not wish to will significantly reduce the enormous burden of disease that combustible cigarettes impose on society. In the United States alone, it is estimated that e-cigarettes have the potential to save up to 6 million lives by 2100 if only 10 percent of current smokers switch to e-cigarettes over the next 10 years. Perhaps the best example is Sweden, where Snus use has displaced combustible use, which boasts the lowest rate of smoking-‐related diseases in the E.U.
While concerns about youth uptake of e-cigarettes and that e-cigarettes could encourage smoking later in life are understandable, they are unfounded. A recent study shows that, in the United States e-cigarette use is much higher among young who currently smoke than youth who have never smoked13. Furthermore, an update from Public Health England indicates that vaping remains low in adolescent never smokers, approximately 0.2 percent of younger never smokers use e-cigarettes1. However, even if the prevalence of e-‐cigarette use increases among younger never smokers, as long as we continue to see combustible use decline this should be considered a positive step in the health and welfare of our global populace.
When considering regulations aimed at reducing the burden of smoking, we strongly urge the Legislative Council to consider the utility of harm reduction and reduced risk products alongside prevention measures. The World Health Organization has gone on record supporting regulatory measures that aim to maximize the benefits of reduced risk products and minimize their risks. We recommend that these products are subject policy and regulatory measures that maintain the safety of these products and increase their availability with the goal of displacing combustible cigarettes. We encourage the Hong Kong Legislative Council keep these products available and we propose that, rather than an outright ban on these products, a proper regulatory framework that encourages a switch from combustibles to reduced risk products will greatly improve the health of your citizens.