Review Ban against E-cigarettes as Alternative for Long-term Smokers

Mr Melvin Yong Yik Chye asked the Minister for Health whether the Ministry will review the ban against e-cigarettes as an alternative for long-term smokers to help them reduce the number of cigarettes smoked.

The Ministry of Health (MOH) has banned Electronic Nicotine Delivery Systems, including e-cigarettes for several reasons.

First, e-cigarettes are harmful to health. Their vapour contains toxic cancer-causing substances, as well as nicotine, which is highly addictive and has harmful effects on foetuses and brain development in adolescents.

Second, experience in other countries shows that there is a danger of e-cigarettes becoming entrenched in Singapore if we lift the ban. For example, an estimated 2.8 million adults in Great Britain used e-cigarettes in 2016, representing a four-fold increase from 700,000 users in 2012. In England, among 11 to 15 year-olds, one in 16 were current e-cigarette users in 2016, a 50% increase from 2014.

Third, e-cigarettes can be a gateway or 'starter product' which hooks youth on nicotine and leads them to cigarette use later. A systematic review of nine studies involving more than 17,000 youths in the United States found that e-cigarette users were three times more likely to become cigarette smokers compared to non-users. Another study among more than 19,000 Canadian youth, showed that e-cigarette users were twice as likely to go on to smoke cigarettes regularly. Other studies in England, Scotland and Poland similarly support this 'gateway effect'.

Nevertheless, we are open to companies registering a specific e-cigarette product under the Health Products Act as a therapeutic product for smoking cessation, if they are able to provide sufficient evidence that the product they are registering is safe and effective.

The current evidence on the role of e-cigarettes in aiding smoking cessation remains limited and mixed. Earlier this year, results from the first randomised controlled trial comparing e-cigarettes and Nicotine Replacement Therapy (NRT) was published. The study involved about 900 smokers with good motivation to quit. When combined with counselling, 18% of the smokers in the e-cigarette group quit smoking at twelve months post-intervention, compared to 10% of smokers from the NRT group. However, in the e-cigarette group, 80% of those who quit smoking continued to use e-cigarettes twelve months later. This means that overall, less than 4% of those in the e-cigarette group quit tobacco product use and their nicotine addiction totally. As there are concerns about the potential harmful effects of long-term use of e-cigarettes, this raises the question of whether they would have been better off quitting using other methods. In addition, more than 30% of those in the e-cigarette group who failed to quit ended up using both cigarettes and e-cigarettes. This leaves them worse off than before, as a recent large study has shown that dual users of cigarettes and e-cigarettes are exposed to more toxins than persons who only smoke cigarettes.

For smokers who wish to quit, there are already approved smoking cessation aids in Singapore which are safe and effective. Smoking cessation counselling, NRT and medications to treat nicotine dependence have all been shown to be effective in helping smokers to quit. There is also the HPB's Quitline for smokers to get more information and support for their quit journey. We will continue to monitor the evidence pertaining to the safety and efficacy of e-cigarettes as a smoking cessation product. Like all therapeutic products for smoking cessation, the onus is on the e-cigarette manufacturer to provide evidence of safety and efficacy. Thus far, none have done so.