Comments to Taiwan Health Promotion Administration regarding the Tobacco Hazards Prevention and Control Act
We are an American physician with a background in health benefits management and smoking cessation and the head of an influential U.S.-based think tank, the R Street Institute, based in Washington, D.C. We are both heavily engaged in tobacco control efforts through work at R Street and write both to praise and to raise questions about your proposals as outlined in the Tobacco Hazards Prevention and Control Act Amendment Bill you are currently considering.
Insofar as the proposals in the bill serve to discourage the use of tobacco cigarettes and reduce your nation’s worryingly high use of cigarettes, we support them and commend you on the proposals. Overall, we support the World Health Organization (WHO) EMPOWER priorities that your proposals embody. Certain provisions under consideration such as the restriction on the sale of all tobacco products to those 18 (a 21 to purchase requirement should also be considered for combustible cigarettes) and over and new taxes on currently duty-free cigarettes are highly likely to reduce smoking; same with restrictions on tobacco promotion. The research on other measures, such as mandates for package-size warning labels and bans on indoor smoking rooms, is less conclusive but these measures, nonetheless, may be worth implementing after careful review of their advantages and disadvantages.
We do, however, strongly disagree with, and urge you to reconsider, the proposals before you that impose an all-out ban on less harmful, non-combustible alternatives to cigarettes. In making your decision, there are at least three facts you ought to consider:
- Smoke from burning tobacco causes almost all of the mortality associated with cigarettes.
Cigarette smoke is a proverbial witches brew of carcinogenic and otherwise harmful compounds. Indeed, there are such a high degree of harmful compounds found in cigarette smoke that scientists still don’t know with certainty which particular ones cause cancer, heart disease, complications in pregnancy and the dozens of other serious maladies clearly associated with smoking.[1] As one of our colleagues at R Street observes, nearly all smoking-related deaths are “associated with a single product: the machine made cigarette.” [2]
Smokers continue to smoke because they are addicted to nicotine found in all combustible cigarettes. As a stimulant, nicotine is associated in the medical literature with a variety of elevated cardiovascular risks similar to those implicit in consuming caffeine found in coffee, tea and sodas. Nicotine also has a well-known impact on the brain and is quite addictive, particularly in younger people. Nicotine also has some positive consequences, such as improved focus and concentration, elevated mood and even relief from symptoms of some mental illness.[3] However, there is little conclusive evidence nicotine itself causes serious disease in humans. Simply because it is so addictive, however, keeping all nicotine away from younger people is good public health policy, but banning it outright is akin to banning caffeine outright; it would likely create a significant black market, deprive adults of something they enjoy and do little to improve public health.
- E-cigarettes, heat-not-burn products (both Electronic Nicotine Delivery Systems or ENDS) chewable tobacco, gums, patches and other forms of nicotine help people transition from smoking to safer ways of consuming nicotine.
While it’s unlikely that any method of consuming nicotine is perfectly safe, there is significant clinical and peer reviewed evidence that ENDS can be an aid to smoking cessation.[4] The United Kingdom, United States and Japan, each of whom allow some or all of these products to be sold, have realized significant declines in smoking rates coincident with the widespread market acceptance of ENDS. These declines, in many cases, come after years of essentially stable and even slightly rising smoking rates.
The United Kingdom’s Public Health England outright endorsed e-cigarettes as 95 percent safer than smoking and a potential aid to smoking cessation.[5] And while these products should almost never be recommended in a public health context to people who do not already smoke, allowing them to be sold and marketed provides a reason and a way for smokers to shift to consuming nicotine in less harmful ways. If these products are banned or their use is limited, the impacts on public health will be strongly negative. This type of harm reduction approach which offers a path between total abstinence from a behavior and continuation of it is a well validated public health strategy as demonstrated by reduction in HIV incidence your country.[6] Extending this successful approach can make your country a world model.
- The thrust of law and public health policies should encourage smokers and tobacco companies to shift away from the use of combustible cigarettes; banning e-cigarettes and like products will make this difficult.
A great deal of research demonstrates age restrictions and efforts to increase the cost of e-cigarettes can have the unintended consequence of leading young people back to smoking traditional cigarettes.[7] The outright ban on e-cigarettes you are considering would likely have even worse effects on the health of your population.
A majority of smokers want to quit and would do so if it were easy. But it is not easy. ENDS provide a way to get them the nicotine they seek. The main impact of an e-cigarette ban will, paradoxically, lead to an increase in the use of traditional cigarettes. If smokers do not have alternative ways to get nicotine that they find as satisfying or almost as satisfying as cigarettes, they will not switch to safer alternatives. The best way to encourage as many people as possible to quit or switch is to offer the maximum number of choices to them. Different combustible tobacco cigarette brands and styles exist because individuals find different flavors, formulations, brand images and nicotine concentrations pleasing. Cigarette companies have had decades to create, market and segment these specific formulations. Unduly restricting types of products and banning particular product categories (including ones that are still nascent) will have enormous negative consequences for public health.
Conclusions
While the proposals before you contain some sound ideas for reducing the use of smoking, others ideas you are considering are deeply flawed. If implemented as currently conceived, they are likely to increase your country’s smoking, reduce access to safer alternative systems for delivering nicotine and result in an increased burden of death and disease. To advance the cause of public health, you should reject these proposals and other proposals that amount to a ban on ENDS.
Respectfully submitted,
Edward Anselm, M.D., Senior Fellow, The R Street Institute
Eli Lehrer, President, The R Street Institute
[1] The Health Consequences of Smoking—50 Years of Progress. Office of the Surgeon General Public Health Service, Department of Health and Human Services; 2014. https://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf
[2]J.L. Nitzkin. “The Case in Favor of E-Cigarettes for Tobacco Harm Reduction,” Int J Environ Res Public Health. 2014 Jun; 11(6): 6459–6471. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4078589/
[3] J. Le Houezec. “The Positive Effects of Nicotine,” Nictoinepolicy.net, https://nicotinepolicy.net/all-authors/85-jacques-le-houezec/640-the-positive-effects-of-nicotine
[4] Edward Anselm. “Doctor’s Orders: E-cigarettes in U.S. Clinical Practice,” The R Street Institute, June, 2016. http://www.rstreet.org/policy-study/doctors-orders-e-cigarettes-in-u-s-clinical-practice/
[5]Public Health England. E-cigarettes: a new foundation for evidence-based policy and practice, August, 2015, https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/454517/Ecigarettes_a_firm_foundation_for_evidence_based_policy_and_practice.pdf
[6] Huang, Yen-Fang, et al. “Changes in HIV Incidence among People Who Inject Drugs in Taiwan following Introduction of a Harm Reduction Program: A Study of Two Cohorts.” PLoS Med 11.4 (2014): e1001625. http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001625
Lin, Ting, Chang-Hsun Chen, and Pesus Chou. “Effects of combination approach on harm reduction programs: the Taiwan experience.” Harm Reduction Journal 13.1 (2016): 23, https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-016-0112-3
[7] Pesko, Michael F., and Janet M. Currie. The Effect of E-Cigarette Minimum Legal Sale Age Laws on Traditional Cigarette Use and Birth Outcomes among Pregnant Teenagers. No. w22792. National Bureau of Economic Research, 2016
Pesko, Michael F., et al. “The effect of potential electronic nicotine delivery system regulations on nicotine product selection.” Addiction (2016).
