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Nicotine vapes as a tool for harm reduction are gaining support in the Southeast Asian country of Malaysia. However, an entrenched illicit combustible tobacco market is making illegal nicotine vapes highly available and dramatically cheaper than those sold legally. This situation presents a significant challenge for health advocates to overcome.

Prof., Dr. Sharifa Ezat Wan Puteh
Physician, Prof. Public Health, National University of Malaysia
Chairman of the Malaysia Society of Harm Reduction


00:00:10 --> 00:00:42

Brent Stafford: Hi, I'm Brent Stafford, and welcome to another edition of RegWatch on GFN.TV. We're here in Warsaw, Poland for the Global Forum on Nicotine 2024. It has been a fantastic event so far. I'm here with Dr. Sharifa Ezat Wan Puteh from Malaysia. So you are a professor and a doctor. So you're a physician, as we like to call it, a doctor doctor. and of public health at the National University of Malaysia. Tell us about that.

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Sharifa Ezat Wan Puteh: Yeah, I'm a medical doctor and my specialty is in public health, hospital health management and also health economics. But we have a new sort of activities coming in which was vape that was many many years ago. So one of my interests came on to vape because it becomes a policy at that point in time for youth not to vape and also smoke. But the more we sort of learn about vaping, we realize this is a potential, you know, alternative for combustible tobacco. And I sort of go into deeper into it. And this is where I end up, you know, looking at.

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Brent Stafford: So are you are you pushing against?

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Sharifa Ezat Wan Puteh: Yeah, of course. Of course. Yeah. Against the tide.

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Brent Stafford: Now, in Malaysia, what are the rules and regulations around nicotine vapes?

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Sharifa Ezat Wan Puteh: Of course, tobacco is seen as something totally negative. We do not want people to smoke combustible tobacco. We have a strong tobacco control. Unfortunately, the prevalence of tobacco users, they are always quite high. At one point in time, it was almost 25%. It has sort of gone down. At the same time, many about five years ago, six years ago, we saw the sort of novice, which is the e-cigarettes, or what we call as vape. At that point in time, a lot of youth actually start switching to vape. And again, the trend in Malaysia, all of these are seen as a tobacco product because we are signatories to the WHO FCTC. So anything that goes related with nicotine are all sort of bundled up as a tobacco product. So all of these are seen negatively. Of course, the control is not very strong at that point in time for vaping. So what happens is that we see a lot of negative effect, not only to the deuce, but there was no comprehensive sort of awareness, input of knowledge on how to use vaping products. The vaping business sort of, you know, just bloomed in Malaysia. There's a lot of industry players. And we're not talking about big tobaccos. We're talking about local producers of vape products. And they are also exporting to other countries. One of the countries is UK. But of course, when they go to UK, we can see that the regulations are very strict. They go through the MHRA, you know, something like what, TPD is in Euro. in the EU. So this is something that Malaysia is hopefully going forward. We had a latest tobacco bill in Parliament last year, which was tabled out. And with that, the government sort of allowed vaping as well, but not for the young, meaning that if you're less than 18, you're not supposed to be vaping. Unfortunately, tobacco is still sold. Of course, we do try to follow the WHOFCTC, meaning plain packaging and things like that. We have an issue of not only illicit vapes, but also tobacco. Some of the reports say that we have a huge burden of illicit cigarettes in Malaysia as well. Some of the Nielsen report from the prevalence of almost 60% of illicit tobacco. It has sort of gone down last year to about 55%. It is still quite high, meaning that for every two persons who smokes combustible cigarettes, one would be using illicit tobacco. That's how big the market is there in Malaysia. And this is something that we worry as well because the illicit vapes are also hugely marketed there. And this is where they actually target the youth and the youngsters, you know, and they become users. Most of this would be disposable vape. And that creates an issue as well because then it will be seen as vape is something totally negative. But they are not using vape as they are supposed to be, a switching method. Another issue, if you have time, Brad, is that because of the illicit cigarettes and also because of the disposable vape, the open system, some of them are taking advantage and also using vape as a mechanism to smoke or use or vape drugs. And again, this creates a whole issue of not only illicit but also people using drugs as well in their vape products. We want that to be curtailed. This is some of the reasons why we come and we want to learn from other countries of how regulations, the policy enforcement and so on.

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Brent Stafford: You mentioned the FCTC a couple of times. What do you think of their policy and their attention to this issue?

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Sharifa Ezat Wan Puteh: I think this is somewhat global as well. Most of the countries that signed the WHO FCTC consider vaping, e-cigarettes are a smoking product, a tobacco product, and we are not supposed to use it. But in Malaysia, I think Tobacco control, we have a specific unit for that by the Ministry of Health, but we still see the issues, you know, it's happening everywhere, including the illicit tobacco. Of course, the government is trying their best, and we do know that, but unfortunately, probably this is not enough. We need new methods to counter these problems and I see at the end of the line some allowance of vaping to be used for people, especially for those who have no intention to quit or people who have failed their NRTs. Nicotine replacement therapy is widely spread in Malaysia. Last year, they have just put it out of the Poison Act, meaning that people will be able to purchase NRT over the counter. However, we realise that the effectiveness and the efficiency of NRT is not so much pronounced in our market as well, in our population as well. So this is where we see that one alternative would be e-cigarettes or alternative nicotine products. However, this has not been met on good terms by the government agencies. Many of the societies actually condemn vaping and e-cigarettes, maybe because of the bad reputation and so on that vape has got. Even though there are good literatures on vape products such as from UK, from Japan and things like that, But because of the tainting of adulterated, you know, vape juice and also using of drugs, this creates a very, you know, bad reputation for vape in many of the countries, including low-middle-income countries such as Malaysia as well.

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Brent Stafford: Yeah, the using of the vape technology to consume drugs, I mean, that's, you know, that's, for one, I mean, the technology is useful for delivering drugs.

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Sharifa Ezat Wan Puteh: Correct, exactly. So this sort of control on the quality of the vape juice, the e-juice basically, is not there yet in Malaysia. So people can still buy online, people can sort of modify their own products and things like that. So what we heard is that the government is coming up with a new regulation, more technicalities, and we hope this will follow suit either from the UK model Or someone would actually recommend the Australian model to be medically advised vaping products to be sold. So these sort of regulations are in the pipeline. This is what we heard. Hopefully there's going to be changes. We hope, cross our fingers. One of the other issues is because of the youth taking up vaping. So this is one of the reasons the government keeps saying that we want to protect the youth. Unfortunately, some of these illegal traders are doing that aggressively for the youth, and again it creates this negative impact on vaping as well.

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Brent Stafford: You know, I'm always suspect, at least in the global north, just in terms of how much, say, you know, a regular tobacco company may be targeting youth, you know, under 18, right? It's such a mess because tobacco control uses the term kids all the time, but they do that for like 18 to 24. And those aren't kids, right? And if you're talking about teens, then use the language to be accurate. And I wonder, is there some misunderstanding as well in Malaysia when it comes to those groupings? Or is it more clear?

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Sharifa Ezat Wan Puteh: I think this is clear. We have to realise in Malaysia as well, the age that people initiate smoking, tobacco smoking, is actually quite low. Some would start at 10, 12, and one of the biggest reasons is because Malaysia many, many years ago also sells tobacco. Many, many years ago. But then we sort of change where the government says that, okay, go into industries, no more tobacco and things like that, which is good. But many elderly or males who are the head of households are tobacco users. So when that happens, when they themselves use tobacco, of course, the sons and mostly male dominated sons and things like that, they will start using tobacco as well. So in most of the situation is that they don't have money to purchase legal cigarettes because it's kind of expensive as well. We have one of the highest tax for tobacco as well globally and also in Asian. So what happens? They turn into illegal cigarettes. which is relatively, I think, three times more cheaper. And you can buy it in single cigarettes as well. So this is something what the kids or youngsters would actually use, even in the rural areas, Brent. So what happens is that now they want to experiment on vaping by the youth. But unfortunately, these are also sold by illegal sellers as well. So then they start using dual users and so on and so forth. So it's very difficult to create the image of a good switching technique when you have all these problems, confounding one after the other.

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Brent Stafford: Well, so is part of the problem not the issue of you have to switch? I'm going to be a bit controversial here, but wouldn't it be better for some young people who may have started with combustible tobacco to first initiate nicotine use with vapes? And shouldn't we encourage that?

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Sharifa Ezat Wan Puteh: Yeah, I've heard a few experts as well mention the same scenario as what you mentioned. I think Malaysia would have a stand that if you have not taken any cigarettes, you are nicotine-naive lungs, don't start. Unfortunately, it's not easy to say that. Of course, in a purist world, we can say that. It doesn't really happen that way. We're trying our best, but the trend shows that tobacco users are decreasing. But there's also an increment of e-cigarette users. So is that bad? That creates a panic in the society. And I keep commenting that this is something which is good as long as the e-cigarettes is being controlled, meaning that it's regulated. We know the compound. What happens is that we don't really know that's the problem. It might be tainted with vitamin E acetate, it might be tainted with diacetyl or something like that. So we don't have that quality control. This is what I would personally emphasize again and again that the government needs to look at this as well, some sort of control on the quality. to make sure that it is really so-called, you know, something which is used for vaping rather than it's being open system and they just put this and that, you know, backdoor industry and this happens as well in Malaysia. They even do this themselves, they just go to the bakery and they take whatever flavour from the bakery and they can actually do an open system, through an open system and just, you know, create so many flavours.

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Brent Stafford: Well, obviously, that's terrible for your health. Correct. Right. Well, so it sounds like to me that Malaysia has imported a bunch of the, you know, problems that the panics, the moral panics.

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Sharifa Ezat Wan Puteh: Right.

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Brent Stafford: They sound like the same moral panics that we've been covering since 2015. Correct. Yep. Yep.

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Sharifa Ezat Wan Puteh: So are these naturally occurring in your country, or are they… Well, we have to realize that most of these are not legal vendors' brands. The legal vendors, the government has mentioned, because of the tobacco bill last year, they have mentioned it's not to be meant for less than 18. Number two, you cannot promote it, advertise it, or encourage people to use vape, so that sort of diminishes all the efforts. Number three is that all the licensed vendors, so-called legal vendors, they must be registered with the government, and they have a website that you have to register. And that's a good trend, that's a good thing, so that you have a control of how many vendors, what are they selling, at least an inventory of that. But later on you have to decide whether you want to allow them to actually sell and teach people the correct method of using. Because at this point in time, there's no one doing it. Some of us are talking about it, but because we are not allowed legally to actually promote it, there's going to be some restrictions. So this is happening in something like India as well. Well, India has a complete ban. Malaysia sort of allowed it. And we have an excise tax on it. That excise tax is not that high. It is almost similar with the combustible cigarettes. So people still can purchase it legally or illegally. And this is what we keep mentioning about the enforcement and things like that. Hopefully, the enforcement is going to be better.

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Brent Stafford: I just don't understand what's different than at 18 you can start drinking, at 18 you could start vaping nicotine. What's different?

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Sharifa Ezat Wan Puteh: At the moment, they allow. Of course, they are frowning even though they allow it. But you can actually purchase vaping products. You can. But like I mentioned just now, because there's no regulation or sort of quality control on the big products.

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Brent Stafford: Well, that has to be happening.

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Sharifa Ezat Wan Puteh: That has to happen.

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Brent Stafford: So in Malaysia, you can promote alcohol, right?

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Sharifa Ezat Wan Puteh: Well... Not in mass media and things like that. Not anymore. You can't?

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Brent Stafford: No. No. So it's primarily Muslim country, right?

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Sharifa Ezat Wan Puteh: Yes.

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Brent Stafford: Right. So is it because of that that there's a... Well, yes, yes, yes. So is there... And so I understand that about alcohol. Has there always been... I've never actually asked this to anybody. Has there been any kind of cultural or religious issue with tobacco in Muslim countries?

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Sharifa Ezat Wan Puteh: Oh, yes. Most of the Muslim countries, including Malaysia, it is seen as something which is haram. Haram means that it's sort of something sinful that you're not supposed to take, and that includes vaping as well, because we consider this is something not nice to use. You're destroying your lungs, you know, you're wasting your money, so why should you be using that? So many of the scholars actually have mentioned it as haram, and Indonesia has done the same thing. Unfortunately, that doesn't really, well, it falls on deaf ears. People still use that. They consider this as a lesser or a small sin compared with alcohol and things like that. So most of the Muslim, you know, guys, they use tobacco, but now they take up vaping.

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Brent Stafford: Well, I think that's got to be a good thing. That's all I can say. So is the WHO and FCTC doing a good thing with how they're trying to legislate?

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Sharifa Ezat Wan Puteh: Well, in a way, they are trying their best in their perspective, of course. But because of the burden of smokers in Malaysia, it's relatively high. And we have not been able to curtail this problem. We have not reached our target of being a smoke-free country. So when that happens, some of us are recommending you look at more innovative ideas, things like alternative nicotine products. It can be in probably a smaller group of subsets of smokers, meaning that people who have no intention to quit, people who have tried NRT and it doesn't work, things like that. This would be a good sort of product for them to actually get to know and properly need and use them. Again, I'm not sure. I don't really think it's going to go into the guidelines. Our guidelines are very traditional. We are very strict on NRT. Most of even our clinical trials, some of the clinical trials that I'm trying to do there also met with frowned eyes because we don't really follow the standards. We should be following the standards and things like that. So this is considered a second line. But at least we start somewhere and trying to push the agenda. But I do believe or some of us do believe that there's going to be a whole subgroup of people who's going to benefit from that. So some of the studies that I found out is that from people who actually convert or try to convert from smoking to vaping sees that even though they start off with dual users when they are trying to switch, but we can see a reduction of the number of sticks that they are using. so meaning that is good it's beneficial for them of course we have to do a longer study where to see whether it's sustainable for them um you know obtaining the e-cigarettes access and whether they are satisfied with that but we see the trend that they are reducing their their tobacco sticks and that relatively is a good thing yeah that's always been what

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Brent Stafford: You know, I've always considered to be the natural kind of way in which that you quit smoking with vaping. There's going to be some time of dual use.

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Sharifa Ezat Wan Puteh: Exactly. But because of brand, there's no proper, there's no regulation to say that you need to label this properly. Some of the vape products, that's a problem. Some of the vape products do not contain the actual nicotine products, the strength. So when that happens, the users become confused. They may be using one box of cigarettes per day and suddenly they are being introduced to like 3%, which doesn't work. So they should start somewhat a bit stronger and things like that. So that sort of labeling and someone who is using very low strength, maybe introduced like 50% or 50 mg per mil, that sort of scenario. So that labeling is not there yet. So this is something that, again, what we mentioned just now, the tobacco bill should cover that as well to make the product safe, but also to make sure that people know how to use it. At the moment, there's no one actually advising them. At the moment, there's one small company who's trying to advocate and, of course, they might be promoting their products and things like that, but they're teaching people how to properly vape using different strengths and things like that.

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Brent Stafford: We hear a lot about, say, the pernicious influence of Bloomberg-funded groups, right? Is that the case in Malaysia?

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Sharifa Ezat Wan Puteh: I really don't have much to say. It's not because I'm scared, but because I don't really know about the Malaysian scenario on Bloomberg. But we do receive, most of our programs, public health programs, actually receive funding either fully or semi from the WHO. It goes down or trickles down to our Ministry of Health, our health promotion boards. I think that's the normal sort of funding for governments. I don't really know whether there's money coming from Bloomberg or things like that. I do know that Bloomberg is funding a lot of WHO programmes. This could be intertwined with them as well.

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Brent Stafford: You're here at the Global Forum on Nicotine. You mentioned a little bit about why you were here, but fully kind of explain why an event like this is important.

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Sharifa Ezat Wan Puteh: Well, when I started out, I had so much doubt on vaping. Most of us in the public health, including myself as a medical doctor, we don't want people to smoke, we don't want people to vape, but in a purist world, it doesn't happen that way. In real world societies, people do get addicted to tobacco, and we have to try, especially for the low-income people, people and so on, our population, to try and advise them how to get rid of that addiction. So that's when I started to sort of learn or get more knowledge on vaping and things like that. And this is where I started attending all the GFN and e-cigarette summits and so forth to learn from experts around the globe. And I think this platform is excellent. And this is where, you know, because if we talk, I mean, local experts, you know, it will just fall on deaf ears. Getting international inputs like this are very important because then you can see how other countries, OECD countries, other low- and middle-income countries are gaining benefit from new knowledge such as alternative nicotine products. I think this is very important. Besides that, we can talk with other experts on how to solve or sort of try to solve our own problems and see what are the intended but also unintended consequences that has happened in their countries that could happen to our own countries. I'll give you an example. That would be something like New Zealand had their GEGs. And, you know, some of the unintended consequences of the GEG has been mentioned by experts from that country. And we sort of, oh, this is internalized on myself as well. Oh, this could happen in Malaysia as well.

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Brent Stafford: Is tobacco control not just people control?

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Sharifa Ezat Wan Puteh: Well, it is. In a way, yep. Controlling people and their behaviors. It's not easy. It doesn't work that way. Sometimes, we as parents can't even control our children. How are we going to control the population in that sense? People have their own minds and have their own incentive for whatever they do.

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Brent Stafford: Is there the same, I'm trying to not be biased to this question, is there the same hatred for big tobacco? from public health and tobacco control in Malaysia.

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Sharifa Ezat Wan Puteh: Oh yes, definitely. Big tobacco is seen negatively and we see vaping as another strategy by big tobacco to promote sort of tobacco to the youth. And of course, it's negatively seen. In fact, there's even a clause. I think this cuts across all government agencies are not to liaise with any of the sort of syntax like alcohol, any companies that promote artificial milk powder, including tobacco companies. So it cuts across. And of course, big tobacco is a total no-no in Malaysia as well.

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Brent Stafford: Do you think that there's room for Big Tobacco to redeem their reputation through smoke-free products?

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Sharifa Ezat Wan Puteh: Yeah, they have the resource to go intense on that. Most of the local industries or small places are not able to do so. In that sense, Well, it's a very difficult question that you put me through, Brent. If they are part of the problem, they should be one of the people who solve it in the long run. But whatever image that they have is not easily redeemable. And people will have doubts of this as well for a very, very long time.