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New lung epidemic on the rise

In good news, many countries have started to experience falling smoking rates – according to Nielsen cigarette sales volume slipped 11.2 percent worldwide in the four-week period ending May 2018. But many Southeast Asian countries are still struggling to curb smoking and, to make matters worse, tobacco companies have been pushing new vapour (e-cigarette) products that smokers think can help them ease off cigarettes.  



Vaping products are made of plastic and use a metal device that heats a liquid nicotine solution (e-juice) in a disposable cartridge. It produces a vapour that simulates the act of smoking. These products are available in over 1,500 flavours , and they are not taxed at the same high rate as cigarettes so they’re significantly cheaper for smokers to buy. As a result, a new vaping epidemic is on the rise evidenced by current market valuation of US $11.5 billion in 2018, with growth expected to reach US $24.2 billion by 2024. 

The side effects 

While the e-vapour market in Asia is currently small compared to cigarettes, experts predict the region will experience the same rapid growth as the US. This is driven by health-conscious consumers with inaccurate information, and millennials who are willing to experiment with new products. The trend is worrying for health officials as the US Food and Drug Administration (FDA) has been investigating the safety of e-cigarettes after reports of seizures and lung illness outbreaks across 38 states. 

Numerous studies show that the aerosol generated by e-cigarettes contains toxic elements and additives. The Centers for Disease Control and Prevention (CDC) has identified 380 confirmed and probable cases, including eight deaths that have been linked to e-cigarettes. Symptoms include shortness of breath, fatigue, chest pain, diarrhea, and vomiting. For those who already have a chronic lung disease, such as asthma, vaping has been linked to an increase in the severity of symptoms.  

A rising number of cases also presented “lipoid” (presence of fat in the lung) pneumonia, but some of these patients admitted vaping THC (the active ingredient in cannabis).  

The cause 

E-cigarettes create an aerosol by heating a complex solution of chemicals, comprising oils, flavouring, and nicotine. The fine particles released are similar in size and concentration to tobacco smoke which means they can reach deep into the users’ lungs. 

While it is known that several of these chemicals are toxic, what makes research difficult is that each product is very different, and the final composition of chemicals is determined by the temperature at which they are heated by the vaping device. 

Some researchers claim that vaping inflames the airways which results in a greater production of mucus and an increase in tissue-degrading enzymes (proteases). One study found that the increase in enzyme levels was also evident with nicotine-free e-cigarette products which suggest that there are other components in the e-cigarette vapour that can cause harm. High levels of proteases can destroy sensitive lung tissue, reduce their ability to function and lead to irreversible lung damage. This can lead to severe lung conditions, including emphysema which is commonly found in chronic obstructive pulmonary disease (COPD). 

Investigation difficulty 

The problem with investigating the harm of e-cigarettes is that there is a large number of products, devices, and flavourings so it is impossible to create a “standardized exposure”. Tests of 166 e-cigarette products showed that 21 percent contain flavouring chemicals (benzyl alcohol, benzaldehyde, vanillin) which are toxic to the airways. The same study also detected other toxic chemicals as well as measurable levels of tobacco-specific nitrosamines (found in tobacco products) in 70 percent of the products tested. But, the effect of inhaling these complex mixtures of chemicals is very difficult to determine.

One substance called vitamin E acetate has been identified in all the samples tested by New York state health officials, but there isn’t enough evidence to say if this is the cause of disease. 

E-vaping bans in Asia

As a result of these studies, vaping is now banned in 30 countries including India and China. Some Southeast Asian countries have supported the ban including Singapore, Philippines, and Thailand while others, including the world’s second-largest tobacco market, Indonesia, are still considering restrictions. 

The Indonesian Personal Vaporiser Association, a group of e-cigarettes importers, vape shop owners and vaping enthusiasts, advocates that the government should hold public discussions with stakeholders before imposing any restrictions. They claim Indonesia has not reported any cases of vaping-related illness, and the rising popularity of e-cigarettes showed that smokers see benefits in switching over from traditional cigarettes. 

Medical cases starting to appear in Asia

Until recently there were no cases of lipoid pneumonia reported outside the US. But, in November 2019, the Department of Health (DOH) in the Philippines confirmed its first case of vaping-associated lung injury. A 16-year old girl suffered from a sudden onset of severe shortness of breath and was admitted to intensive care where she received oxygen supplementation. It was reported that she had been using e-cigarettes and cigarettes for six months.

One month later, Thailand also reported its first case of pneumonia from e-cigarettes when a 48-year old male patient was admitted to hospital for breathing problems. The man told doctors he developed shortness of breath, fatigue, fever and chest pain soon after he started smoking e-cigarettes. Lab tests revealed symptoms consistent with pneumonia from electronic cigarette use, according to the criteria set out by the US CDC . The patient recovered after being treated with intravenous steroid therapy.

The bottom line

The evidence to date clearly suggests that vaping is not a safe alternative to smoking tobacco and healthcare providers play a critical role in detecting cases. When faced with patients with symptoms of shortness of breath, fatigue, chest pain, diarrhea and vomiting patients should be questioned on their e-cigarette usage and the necessary lab tests should be arranged. This is the only way we can heighten awareness of this ongoing problem and prevent yet another generation from suffering from chronic lung diseases. 

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