Harm reduction. Electronic cigarettes are on display during the First Asia Harm Reduction Forum in Jakarta.

Vapers, experts and members of the academe lead the discussion during the First Asia Harm Reduction Forum in Jakarta.

Vapers and vaping advocates from different Asian countries have gathered for the first time in Jakarta, Indonesia to call on their governments to allow and regulate the use of electronic cigarettes and the so-called ‘heat-not-burn’ tobacco products which are considered less harmful alternatives to smoking. “Vaping or choosing a better product [than cigarette] is a human right. But we still have to fight for it,” Dimas Jeremia, chairman of MOVI or Indonesian Vape Retailers, says in a panel discussion during the First Asia Harm Reduction Forum at Shangri-La Hotel Jakarta. Vaping or the use of e-cigarette is considered as a harm reduction tool, according to experts.Vaping is an act of inhaling and exhaling the vapor produced by an electronic cigarette—a battery-operated device which vaporizes a flavored liquid made of nicotine, propylene glycol, glycerine and flavorings. Vaping is considered as a significantly less harmful practice compared to the traditional burning of cigarettes, according to studies. While there are no specific data on the population of Asian vapers, it is estimated that millions in the region now use e-cigarettes and heat sticks which advocates also classify as harm reduction products. Harm reduction is a strategy in public health science to reduce the negative impact of a product or practice. The World Health Organization says that in 2015, over 1.1 billion people smoked tobacco and tobacco smoking would kill up to half of its users. It is believed that smoking kills more than 7 million people each year, making the tobacco epidemic one of the biggest public health threats the world has ever faced. WHO also does not endorse vaping. Prof. Achmad Syawqie Yazid, chief of YPKP Indonesia (Public Health Observer Foundation), which organized the forum, says almost half of the world’s 1.1 billion smokers live in Asia, with India and Indonesia having among the biggest populations of smokers globally. Thousands die each day in these countries due to complications related to smoking such as heart disease and cancer.“One of the major health problems in Indonesia is caused by its extremely high cigarette consumption. In fact, smoking rate in Indonesia is one of the highest in the world today, reaching more than 57 million Indonesians. Today, Asia has the largest number of cigarette smokers anywhere in the world. Despite best efforts and various approaches by public health policies in fighting the cigarette smoking epidemic in the region, smoking rates have stopped declining,” Yazid says. “This condition motivates us, public health observers in Asia, to immediately seek for the most efficient solutions to mitigate the risks of burning tobacco. Countries in Asia need to take actions,” says Yazid. Yazid says one of the most efficient solutions is by introducing alternative tobacco products with lower health risks such as nicotine patch, Swedish snus, e-cigarettes or vape and heat-not-burn tobacco products, referring to heat sticks. “In countries that promote the use of electronic cigarettes and heat-not-burn tobacco products such as Japan and the UK, smoking prevalence has been declining at a record speed. In the UK for example, 2.2 million smokers have quit smoking within five years. Japan has the world’s fastest decline in cigarette use since two years ago. The US FDA just announced this year that its anti-tobacco regulation will be fully geared towards harm reduction while New Zealand Ministry of Health just endorsed this month the use of electronic cigarettes,” says Yazid. Dr. Konstantinos Farsalinos, a Greek cardiologist and a top researcher on harm reduction tool, says people die from tar, or the byproduct of burning cigarettes, and not from nicotine. “Nicotine has not killed a single smoker. Nicotine is not a carcinogen. It is combustion that releases harmful toxins,” he says. Farsalinos says based on voluminous studies, the use of e-cigarettes is substantially less harmful than burning tobacco. He says switching to e-cigarettes from smoking results in more than 95-percent reduction in the release of carcinogens like formaldehyde, acetaldehyde and acrolein. “I think e-cigarettes, without any doubt at all, from all the literature, are by far, by a very large margin, less harmful than smoking. There is absolutely no doubt, and there is no discussion about it,” he says. Rajesh Sharan, a professor of Molecular Biology at North Eastern Hill University in India, agrees, saying vaping releases much less or insignificant cancer-causing agents. “Vaping has minimum health and safety concerns compared to high risk associated with cigarette,” he says in the same forum. “It is a potentially effective avenue for quitting smoking or smoking cessation,” says Sharan. It has become an effective tool to quit smoking, because it mimics the experience of smoking and still provides nicotine. “In 2014, 6.1 million Europeans quit smoking with the help of e-cigarettes. An additional 9.2 million reduced smoking with e-cigarettes. E-cigarettes promote smoking cessation,” says Farsalinos. “Millions of lives can be saved in Indonesia, Asia and worldwide at no cost to the economy and the state,” he says. Farsalinos, however, says there is a need to regulate vaping particularly in Asia, where many countries impose an outright ban or restrictions on e-cigarettes, while allowing tobacco smoking to flourish. In Southeast Asia, Brunei, Cambodia, Indonesia, Singapore, Thailand and Vietnam impose a ban or restrictions on the use of e-cigarettes. Authorities in Malaysia and the Philippines also look at restricting the vaping industry. “There are countries in the world, some of them in Southeast Asia which have banned these products, but tobacco cigarettes have not been banned. That is an entire paradox and it does not make sense,” says Farsalinos. Donald Low, an associate dean of Lee Kuan Yew School of Public Policy at the National University of Singapore, says despite the compelling benefits that harm reduction products bring, there are still authorities that decide on outright ban. Andrew Da Roza, an addiction psycho therapist, says Singapore is one of the world’s leaders in tobacco control, but it has rejected tobacco harm reduction. Dr. Drg. Amaliya, a dentist at Padjajaran University of Indonesia, says while vaping is not legal in Indonesia, “I could not say it is illegal, because it is not currently regulated or monitored.“There are plenty of vape shops or cafes in Indonesia. Marketing, awareness and use of e-cigarettes is growing rapidly in Indonesia, despite the lack of regulation,” Amaliya says. Farsalinos says e-cigarettes have the potential to save thousands of smokers in Indonesia from premature death. In Indonesia alone, some 300,000 people die due to smoking (annually), he says. “There are 57 million smokers in Indonesia. Tobacco is the most lethal product containing nicotine.” Meanwhile, the Philippines has recently excluded vaping from a nationwide ban on smoking in public places. Data from the Philippine Statistics Authority show that in 2015, 16.6 million adults or 23.8 percent of the Philippine population were smokers. Of the total, 76.7 percent planned or were thinking about quitting, but only 4 percent were able to successfully quit. Many Filipinos switched to vaping when the government issued an executive order prohibiting smoking in public places, according to Tom Pinlac, president of The Vapers Philippines. In the Philippines, about 4 million or 4 percent of the population are vapers, he says. There are more than 2,000 e-cigarette juice manufacturers in the country, mostly individuals, which makes the market basically informal. “A lot of juice manufacturers are individuals. It is still in the early stages, but it has been growing rapidly over the past two or three years,” Pinlac says. In Malaysia, vaping is also not entirely prohibited. A local research shows that 75 percent of respondents choose e-cigarettes because of health concerns over smoking. Azrul Hafriz of the Malaysian Organization of Vape Entity says the country has many vape shops and even exports e-cigarette juices with different flavors to the UK, Europe and Thailand. Recent news, however, have alarmed the vaping community. “News of enforcing a ban has triggered fears within the vaping community in Malaysia. Everyone including brewers, retailers and consumers were afraid that their rights to vape would be taken away from them. We are not against the government. Regulation is important so that we are assured of quality and safety of products as alternative to smoking,” says Hafriz. In Thailand, it is illegal to import, manufacture, advertise or give services related to vaping, according to Asa Saligupta of Ends Cigarette Smoke Thailand. “But it is not illegal to vape,” he says. “The amount of users is estimated at least 400,000 people using vaporizers. Almost everything is underground at the moment,” Saligupta says. Saligupta says as a result of the ban, the 11 million smokers in Thailand have no choice. “We have started an online petition to lift the ban on e-cigarettes. We have 10,000 signatures and counting. We need your support,” he says. Shakrit Rimpanit, a cessation clinic doctor of Saint Mary Hospital of Thailand, says more clinical studies are needed to convince authorities on the merits of vaping. Meanwhile, India has several territories that also restrict the use of e-cigarettes, says Nilesh Jain, the founder and managing director of ivape.in. “Over the last two and a half years, we have been pushing products or technology for harm reduction. We have reached over a million users. The focus is a lot about what vaping means and on education,” Jain says. Jain wants more people to consider harm reduction tool, because of the serious problem in India, where smoking kills 1 million people and costs $16 billion in economic losses each year. Farsalinos challenged the vaping industry to come up with more studies or solid evidence to convince authorities on the merits of vaping. “Many countries don’t have data. One of the biggest problems is the lack of knowledge on the situation on the ground. You must also show that you are a responsible industry. You have to create a good image for the product,” he says. A study is currently being undertaken in the Philippines. Researchers Ron Christian Sison and Jay Jazul from the University of Santo Tomas began a study analyzing the urine samples of smokers, non-smokers and vapers. In Indonesia, YPKP as an organization carried out a research to evaluate e-liquid ingredients and observe the oral condition of smokers and vapers. These studies are expected to add to the current literature on harm reduction products and provide local evidence needed by authorities in making policy decisions. Jeannie Cameron, the founder and managing director of JCIC International in Australia, believes that harm reduction products have the potential to overtake tobacco cigarettes over time. “There is a huge potential in this area. It is the biggest disruption in the tobacco industry,” she says. Yazid, the organizer of the forum, says if governments in Asia would embrace new technologies such as e-cigarettes, more Asian smokers could switch to less harmful alternatives. “If new policies encourage harm reduction alternatives, the public health benefits can be unprecedented and even more so in Asian countries where smoking rates are high,” he says.