University of Philippines Manila

From Cigarettes to Vapes: The New Health Challenge

Speakers Dr. Marian Encarnita ‘Maricar’ Limpin and Dr. Leonora Fernandez discussed the detrimental health effects of smoking in the 199th episode of the Health Updates webinar series titled “Paninigarilyo at Vape, Ihinto na! How to Protect Future Generations,” last July 5. 2024, together with hosts Dr. Stella Marie Jose and Dr. Raymond Francis Sarmiento.

Text by: Charmaine A. Lingdas

“For us health care providers, we always apply the precautionary principle, meaning we must exercise caution until safety is proven for any potential disease-causing agent. That’s why you’ll never hear us recommend the use of electronic cigarettes.”

This was the assertion of Dr. Maria Encarnita ‘Maricar’ Limpin, a tobacco cessation expert and Executive Director of Action on Smoking and Health Philippines, as she firmly stated her stance against promoting vape as an alternative to cigarette smoking during the webinar series titled “Paninigarilyo at Vape, Ihinto na! How to Protect Future Generations,” last July 5. 2024, the 199th episode of Health Updates.

This comprehensive presentation on the public health impact of smoking and vaping in the Philippines highlighted their detrimental health effects contrary to claims of the tobacco industry.

 “Yung sinasabi nilang less harmful or harm reduction, hindi yan bagong strategy, that has been used already even before,” said Dr. Limpin, recounting the time when tobacco industry offered low tar, low nicotine cigarettes to consumers as a ‘healthier’ alternative to smoking. “But time has shown us that whatever you smoke, you will still get disease and still die from tobacco use. Sinasabi na naman nila yan with vape that they are offering a safer and healthy alternative. Please do not be fooled anymore by the tobacco industry.”

Alarming Statistics

Dr. Limpin highlighted that smoking and secondhand smoke are linked to various cancers (lung, liver, colorectal), chronic diseases (stroke, coronary artery disease), COPD, and respiratory problems in children. She noted that lung cancer is now the second leading cause of cancer death among Filipinos, and although the usage of tobacco is declining, there arose another problem.

“While we are gradually reducing tobacco use, we now face another challenge: the rise in the use of electronic smoking devices,” Dr. Limpin said, citing the data from the Global Adult Tobacco Survey (GATS) and the Global Youth Tobacco Survey (GYTS), expressing concern over persistently high prevalence rates compared to neighboring ASEAN countries. 

In 2009, 29.5% of adults smoked, a figure that decreased to 19.6% by 2021. Among youths aged thirteen to fifteen, there was also a decline, with the highest prevalence of smoking recorded in 2007 at 27.3%.

Globally, however, there has been a significant increase in the number of people using vape products. In the Philippines, there is a growing trend of younger individuals using e-cigarettes. According to the GYTS in 2019, 14.1% of youths aged 13-15 were already using e-cigarettes. Data from the National Nutrition Survey in 2019 indicates that 44% of vapers are nonsmokers. 

“Thus, the tobacco industry’s claim that they promote vaping as a smoking alternative is not true. Most who are vaping are young and have never really smoked,” she added that there is increased harm because smokers are more likely to use both products.

Misconceptions and Real Dangers

Dr. Limpin debunked the notion that vaping is safer than smoking, presenting evidence that many e-liquids, even those labeled nicotine-free, contain nicotine and harmful chemicals. She categorized electronic smoking devices or e-cigarettes or vapes into three types: electronic nicotine delivery systems (ENDS), electronic non-nicotine delivery systems (ENNDS), and heated tobacco products (HTP or “heat not burn”).

She cautioned against the misconception that vaping emissions are vapor. “It’s not vapor; it’s an aerosol, similar to tobacco smoke, containing solid particles and various chemicals,” she clarified. “Heated tobacco products and electronic smoking devices operate on a principle similar to traditional cigarettes— hindi nga lang sinisindihan, but they are being heated at a temperature where in toxic chemicals are generated and that is exactly what the smoker or vaper will be able to inhale and exhale in the form of an aerosol.”

Dr. Limpin explained that traditional tobacco cigarettes involve combustion, generating smoke in a combustion zone with temperatures between 700 to 950 degrees Celsius. In contrast, heated tobacco products only heat the tobacco up to 350 degrees Celsius. However, toxicants and volatile compounds are primarily produced at temperatures below 200 to 350 degrees Celsius in both methods, forming an aerosol that smokers inhale.

Dr. Limpin discussed chemicals in e-cigarettes identified by the US FDA as harmful or potentially harmful, such as tobacco-specific nitrosamines (TSNAs), known carcinogens; acrolein, a respiratory irritant produced when glycerol is heated; and formaldehyde and acetaldehyde, both cancer-causing agents formed from propylene glycol oxidation in e-liquids. 

“Vaping does not reduce harm; it increases the risk of diseases, including cancer and cardiovascular issues,” she stressed. She highlighted cases of EVALI (electronic vape-associated lung injury), noting studies showing DNA and genomic changes among vapers. Sweet-flavored vapes were particularly linked to high levels of DNA damage, followed by mint or menthol, then fruit-flavored vapes.

Researchers from the University of the Philippines – Philippine General Hospital (UP-PGH) have published a case report detailing an instance of acute myocardial infarction and e-cigarette or vaping-use associated lung injury (EVALI) in a young Filipino man who regularly used e-cigarettes. (nih.gov) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11023740/

Marketing Targeting The Youth

Dr. Limpin highlighted deceptive marketing tactics by vape manufacturers targeting youth. Originally unattractive, vaping products have been redesigned to be more appealing and colorful, especially resembling toys or anime-themed gadgets with bright lanyards. “We’re seeing students proudly display various pods and e-cigarettes,” she observed. She warned parents and educators to remain vigilant, as students may wear electronic smoking devices disguised as flash drives around their necks, mistaking them for harmless gadgets.

“There is this kind of reasoning now in the younger ones that passionate defiance, ‘kung ito yung mas uso at mas cool ako pag ginagawa ko ito, nobody can tell me what to do. This is my option, this is my personal choice so I will continue to do it’ and that is a strong motivator for them to continue to smoke,” explained Dr. Leonora Fernandez, Professor and Pulmonologist in the UP College of Medicine and UP-Philippine General Hospital. Apart from dependence and addiction, older studies cite reasons Filipino youth start smoking despite awareness of risks that include peer pressure, family influence, curiosity (especially among youths trying vaping), and a desire to appear relaxed or cool.

“Smoking is not just a habit. Vaping is not just a habit nowadays. Ito yung gusto nating paradigm shift, we think of smoking not as a risk factor, but it is a disease and an illness by itself. It is a medical disorder. It is a chronic relapsing disorder called nicotine dependence syndrome.”

Public Health Efforts

“As health care practitioners ito po yung focus. Those who continue to smoke and those who vape would need all the utmost help from us to help them really stop smoking and vaping because they cannot do it by themselves,” said Dr. Fernandez. She noted the 2021 data shows two-thirds expressed willingness to quit, half attempting in the past year, but only 4% succeeded. She underscored that there is a 40% gap needing support for successful quitting, and questions for the person about their smoking or vaping should be part of the patient interview.

She identified several avenues that can help with smoking cessation: PhilHealth offers reimbursement of ₱7,800 for dependency treatment. The World Health Organization has a tobacco cessation guideline available online, and the Philippines contributed to its development. Additionally, local guidelines are available online to assist in setting up a cessation service.

Dr. Fernandez advocates the ABC approach and the STAR method:

  • Ask about tobacco use 
  • Brief advice to quit 
  • Connect to cessation support
  • Set the quit date 
  • Tell family and friends 
  • Anticipate challenges,
  • Remove tobacco products. 

The four Ds approach—Delay, Drink water, Distract, and Deep breath—also helps, according to her.

Quitting often requires multiple attempts; pharmacological treatments like nicotine replacement therapies (gums, patches) aid withdrawal and craving management for up to three months post-cessation. “The key is motivation to quit, a predictor of success,” she emphasized. 

She stressed a multi-pronged approach and collective effort to reduce tobacco production, eliminate smoking and vaping. She also highlighted 33 countries banning the marketing of vape and urged the Philippines to consider joining this movement. 

“We encourage everybody to write it down, and then you can email DOH,” appealed Dr. Fernandez to the health workers to document any vape-related illnesses. “We still don’t have the registry of any vape-related medical adverse event or adverse illness that your patients would have. This is the only way we can prove and combat them so otherwise it’s all hearsay and we have nothing to prove when we go fight them in the legal aspect.” #


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