Professor Sharifa Ezat Wan Puteh moderated a highly interesting discussion between prominent speakers from Hong Kong, Philippines, and Malaysia, which focused on the complex landscape of tobacco use and regulation in Asia, and the importance of balancing regulation with harm reduction strategies to effectively address tobacco and nicotine use in the region.
The landscape of tobacco use and regulation in Asia
Highlighting the significant burden of tobacco consumption particularly among males, Professor Wan Puteh pointed out in her opening remarks that the prevalence of tobacco use is around 30 – 40% in most of Asian countries, with few exceptions, such as Singapore or Hong Kong. While alternative nicotine products —mainly e-cigarettes— are emerging, regulatory responses vary widely across nations. Countries such as the Philippines and Indonesia have adopted more favourable laws towards vaping, yet challenges like illicit tobacco sales and youth access remain critical issues. Malaysia’s high rates of illicit cigarette consumption complicate efforts to reduce smoking rates, despite high taxation measures. Professor Wan Puteh referred also to the 2022 Vape Law of Philippines, which is the first of its kind in Asian lower- & middle-income countries (LMIC). In Philippines smoking prevalence is also quite high, she said, and the prevalence of quitting smoking is quite low. The new Vape Law imposes restrictions on where vaping products can be sold; penalties for stores and online retailers that sell to minors and restricts advertising. Hong Kong, on the other hand, has a quite low smoking rate, and a ban on all alternative smoking products. Their Tobacco Control Bill includes measures to phase out all types of flavoured cigarettes and ban smoking in public areas, and the government plan to reduce the smoking rate to 7.8% until the end of 2025.
According to many reports, she said, a combination of not only abstinence, but also harm reduction strategies for switching from tobacco use to reduced risk products use could lead to a significant reduction of smoking-related morbidity and mortality. Taking advantage of new cessation and harm reduction technologies could lead to 3 – 4 million fewer annual deaths from tobacco within four decades, Professor Wan Puteh explained. “There is no other public health issue where the potential gains approach that order of magnitude,” she stressed. In Asia, the war against addiction and drug addiction includes strict strategies, such as criminalization and sentencing, even the death penalty for drug offenses, Professor added. But these policies have been proven ineffective in many Asian countries, so there is a need for the implementation of other strategies, such as harm reduction policies, regulation, expanding access, as well as prevention and education.
Hong Kong has adopted a very strict legislation against e-cigarettes, vaping, and all the alternative nicotine products, Professor Wan Puteh said and gave the floor to Dr. Wong from Hong Kong to share his thoughts regarding the role of alternatives in the fight against tobacco in Asia.
The case of Hong Kong – Ban on all alternatives
Dr. Chung-Hin Willy Wong addressed the implications of Hong Kong’s 2022 ban on alternative smoking products, noting a significant drop in smoking rates from the 1980s to the present. Despite this progress, he pointed out that many smokers still seek alternatives to combustible cigarettes, as current cessation services are insufficient.
Hong Kong is a very small place, quite crowded, Dr. Wong said, and according to the statistics there are around 630,000 smokers in the city. Hong Kong saw a drastic decrease of the smoking rates from 20-23% in the 1980s to about 9% nowadays, which is close to the government’s target of 7% for the end of this year. But despite this low smoking rate, alternative smoking products are still needed. After 2022, when the new law passed in Hong Kong and banned all alternative smoking products, some smokers feel that they are being forced to switch back to smoking combustible cigarettes, and that their rights for better health are not safeguarded or respected. Although some smokers try to use the public cessation services to quit smoking, sometimes they need more time and if they fail, their only option is to switch back to the combustible cigarettes.
“Quitting smoking is not an easy journey”, Dr. Wong underlined; “it sometimes takes quite a long time, and sometimes in the middle of the journey, people relapse to smoking. When this happens, if they have alternatives, they could choose smokeless products instead of the combustible cigarettes, but now they are deprived of all these choices.”
Smoking cessation services, provided in the public setting, don’t offer any medication such as bupropion or varenicline, they just offer nicotine replacement therapy, like gums and patches, as well as some brief counselling, which is not enough for some smokers to help them quit smoking eventually.
The issue has been further complicated by an emerging scene and trend of abuse of drugs using the vaping devices, he added. Since 2024, an increasing number of people started to use etomidate, which is a short-acting anaesthetic drug, through the e-cigarette devices. Of course, this is also the case in many other countries where alternative tobacco products are allowed or regulated, but the total ban on these products in Hong Kong has led to secretive usage, complicating the ability of healthcare providers to address the problem effectively, Dr. Wong said.
The current tobacco control policies in Hong Kong mainly focus on regulating the supply of tobacco, suppressing the demand for smoking, banning promotion, reducing attractiveness of the smoking products, expanding the no smoking areas, enhancing education, and supporting cessation, the speaker concluded. However, there are concerns about the increasing illicit market in the country and the health risks associated with unregulated products. To lower further the smoking rate in the country, Dr. Wong suggested, the government must reconsider its current tobacco control policy and the usefulness of the alternative tobacco smoking products. A complete tobacco control policy should include abstinence, prevention, and harm reduction. People should be given time and support to change from a smoker to a non-smoker. Since vaping and heated tobacco products have already been banned, maybe oral nicotine pouches, which is a truly smokeless product, could be considered in the future as a potential —additional to nicotine replacement therapy— option to help smokers.
The case of Philippines – The first Vape Law in Asian LMIC
Dr. Fernando Fernandez, a distinguished oral and maxillofacial surgeon from the Philippines, discussed the positive effects of the Vape Law, which has been in effect since 2022 in the country, and has facilitated smoking cessation efforts among healthcare professionals. The law has empowered healthcare professionals to advocate for smoking cessation and educate patients about alternative tobacco products, thereby enhancing oral health initiatives, Dr. Fernandez explained.
The Tobacco Harm Reduction strategy is very effective in the Philippines, the speaker said. The Vape Law provides a comprehensive regulatory framework covering the importation, manufacturing, sale, packaging, distribution, and use of the vaporized nicotine and non-nicotine products and the novel tobacco products. It provides also for penalties in case of violation; restricts access to tobacco products for minors, by banning the various flavours and prohibiting selling these products near schools. The law also states that only 18-year-olds and above can purchase these novel tobacco products. An extra benefit of the Vape Law comes from the excise tax, Dr. Fernandez mentioned, which can be used to fund the national health insurance. Of course, there are still oppositions, anti-tobacco groups that are spreading false information about nicotine and heated tobacco products and are accusing of unethical practice the medical community who supported the Vape Law, the speaker concluded.
The case of Malaysia – Challenges for Tobacco Harm Reduction
Professor Kasinather B. Vicknasingam, a specialist on Addiction, presented on the challenges of implementing Tobacco Harm Reduction in Malaysia, emphasizing that while drug harm reduction programs have successfully decreased HIV infection, tobacco use among drug users persists at very high rates. Unfortunately, he said, drug harm reduction and tobacco harm reduction are not aligned.
Until the early 2000s, Professor Vicknasingam explained, many parts of the Asian region had very strict, harsh laws for drug users, and it was very difficult to introduce not only harm reduction, but even treatment programs. But the HIV epidemic in Malaysia opened the door for providing drug treatment and introducing harm reduction programs, because HIV was infecting the general population, not only the drug user population. Within a decade after the introduction of harm reduction programs in Malaysia, HIV infections were reduced from about 80% to 10%, demonstrating the effectiveness of these programs. But, while harm reduction for drug users was necessitated by the HIV epidemic, THR is not related to an infectious disease, the speaker said.
The introduction and acceptance of tobacco harm reduction —with the use of e-cigarettes and vaping products— poses also a challenge because of the stigma associated with tobacco harm reduction products, which are primarily produced by the industry. Additionally, there is lack of THR advocacy in society distinguishing the effects of health and managing dependence. Many doctors do not understand that tobacco addiction means that it is a chronic relapsing disorder. Unfortunately, Professor Vicknasingam said, the term “smoking cessation” creates an unrealistic expectation that there is an endpoint to this, and the endpoint is soon. Therefore, the ethos of addiction needs to be put forward and explained very clearly to people, the speaker said and advocated for realistic treatment goals that focus on improved social functioning rather than complete abstinence.
Professor Vicknasingam also underscored the challenges of preventing adolescent vaping and drug abuse in Malaysia, particularly in light of the proposed ban. “Today there are very loud calls to ban vaping,” he said, and expressed his concerns that such a ban would not stop current users but instead push the market underground, resulting in unregulated and potentially dangerous products. “When you regulate something, you have control over it,” Professor Vicknasingam stated, advocating for regulation over prohibition as a more effective way to manage the issue.