Taiwan Is About to Ban the Use of Nicotine Vapes

Taiwan looks set to become the next country in Asia to ban nicotine vaping products.

On January 12, amendments to the Tobacco Hazards Prevention Act effectively cleared the legislative floor. Now, the legislation only awaits a presidential nod—a formality given that President Tsai Ing-wen is from the ruling Democratic Progressive Party that proposed it. 

The news, which arrives not long after the Philippines enacted relatively pro-vape regulations, has elicited strong reactions from consumers, policy experts and medical experts, who had some hopes that the tide might be turning in favor of tobacco harm reduction (THR). 

Taiwan appears to be emulating regulations in nearby Japan, where heated tobacco products (HTPs) are sold legally but nicotine vapes are prohibited. The availability of HTPs in Japan has seen a dramatic reduction in cigarette sales. But THR advocates will wonder why an option indicated to have an even lower risk profile—and shown to be a more effective smoking cessation aid than nicotine replacement therapy—is about to become formally illegal. Other Asian countries to have banned vapes include India and Thailand

In Taiwan’s strained governmental nomenclature, HTPs have been classified “designated tobacco products” and are subject to regulation, while vaping devices have been accorded the category of “tobacco-like products.” The imminent ban includes use of e-cigarettes, with penalties of up to $330 for violations. (Previously, vapes had existed in something of a legal gray area.)

This has ignited debate in Taiwan, a country of 24 million where 13 percent of the population smokes, including almost a quarter of men. While millions of upset vape users have been left in the lurch, anti-tobacco groups are meanwhile demanding HTPs be banned too. The law, which will likely come into effect in a month after the presidential assent, will inevitably force vape shops to close and a rapidly growing industry to shutter or go underground.

While it’s difficult to deduce the motivations for the legislative decision, Taiwan policy experts and vape users point to a combination of misinformation, financial considerations trumping public health, and the positions taken by World Health Organization’s Framework Convention for Tobacco Control (WHO FCTC) on novel nicotine alternatives.

“The issue did not have enough public discussion and the approach to harm reduction should be more thoroughly debated,” Simon Lee, the Taiwan policy fellow at Consumer Choice Center, a global consumer advocacy group in Washington, told Filter. “For instance, we have seen misinformation, especially with regard to nicotine, circulating among anti-tobacco activists. It is beyond reasonable doubt that Taiwan’s consumers deserve a much better outcome.”

Read the full text here

Thailand police crackdown on tourists with vape devices shows they desperately need harm reduction policies

Harm reduction vs. smoking

If you happen to practice harm reduction and have a vape device in your pocket, it seems Thailand is the last place you’re going to want to visit.

In the last few days, it was revealed that police officers allegedly extorted a Taiwanese actress of more than 27,000 baht ($820) for…wait for it…having a vaping device.

Taiwanese actress Charlene An got into a taxi with friends after a night out in the Thai capital and was caught with a vape and was held by the police and not allowed to leave until she paid the steep fine.

The police officers have at last been transferred and may face their own charges, while the police have been forced to apologize to the Taiwanese tourist for the gross misstep.

This is not only an abuse of power and irresponsible in its own right, but it proves again why Thailand must modernize its policies on harm reduction and embrace alternatives to smoking like vaping and other products.

Before that, in 2019, a tourist from France was arrested, fined, jailed and deported just for vaping. She had to bear legal costs, expenses and fines of approximately 286,000 Baht ($8730) in just one week.

For any tourist, this can be unsettling, but it’s even more problematic that local residents don’t have access to legal harm reduction products. This is what happens when the government’s own policy sees vaping as a threat.

The Thai government must immediately re-evaluate their policy on vaping and take into account the proposal from Minister Thanakamanusorn to legalize the use of vaping as a way to give smokers the option to quit.

The government should replicate the implementation of policies in countries such as the United Kingdom that have succeeded in significantly reducing smoking rates through the recognition of harm reduction as the main strategy.

Based on data recently released by the United Kingdom’s Office for National Statistics, the number of smokers aged 18 and over has decreased from 14.0 percent in 2020 to 13.3 percent in 2021. In fact, this is the most effective decrease since it was first recorded in 2011 by 20.2 percent.

In August last year, Thailand’s Public Health Minister and Deputy Prime Minister Anutin Charnvirakul stated that e-cigarettes pose significant health risks to users and that vaping helps create new smokers, especially among young people in Thailand.

Based on a recent study by the Office for Health Improvement & Disparities United Kingdom stated vaping significantly lowered exposure to harmful substances compared to smoking, as shown by biomarkers associated with the risk of cancer, respiratory and cardiovascular conditions.

Besides, an analytical survey by Lee, Coombs dan Afolalu (2018) said the actual factors of vaping among youth have yet to be proven. In addition, according to the Royal College of Physicians, reports stating that teenagers who use vaping are at risk of potentially giving birth to a generation affected by nicotine are not based on evidence.

If policymakers took this into account, perhaps there would be more people with different options for harm reduction in Thailand, and perhaps less cases of abuse by police officers.

Tarmizi Anuwar is the Malaysia Country Associate of the Consumer Choice Center.

Smart regulation helps prevent underage vaping

KUALA LUMPUR, 27 January 2023 – The Consumer Choice Center (CCC) agrees with Malaysia’s Health Minister Dr Zaliha Mustafa regarding concerns about the sale of vape products to children.

According to the representative of the Malaysian Consumer Choice Center, Tarmizi Anuwar does not support vaping by youth or children under 18 years of age and suggests that the government quickly implement smart laws to regulate the sale and marketing of vape products. 

“Underage children should not be allowed to buy vape products. In order to avoid or reduce the risk of this happening, the government needs to create a separate law or expand current tobacco regulations for the sale and marketing of vape.”

“There are several steps that the government can take including introducing smart regulations and enforcing strict age restrictions on vaping devices and liquids at the point of sale and using modern age verification technology for online sales.”

“The absence of laws will make it easier for children to obtain vapes from black market activities and illegal trade.”

Elaborating on Dr Zaliha’s statement regarding the classification of nicotine under the Poisons Act 1952, he said, “Nicotine replacement products have already been exempted from the Poisons Act 1952 in October last year. This means that nicotine is no longer considered a non-toxic product.”

“Technically, vape can be considered as a nicotine replacement product because the main purpose is to be used as an aid to quit smoking.”

“However, this is one of the areas of public policy that still need to be improved so that there is no confusion.”

In addition, Tarmizi emphasized that this law is also important in differentiating vape products between responsible adult users and children.

“This law is important to ensure that adult consumers have a legitimate choice to choose products that are less risky and harmful and move towards a healthier lifestyle.”

“The government is also not justified in using this argument to limit access to responsible users because it has not yet been proven about reports or articles that link vaping as a gateway to smoking.”

Based on an analytical survey by Lee, Coombs dan Afolalu (2018) said the actual factors of vaping among youth have yet to be proven. In addition, according to the Royal College of Physicians, reports stating that teenagers who use vaping are at risk of potentially giving birth to a generation affected by nicotine are not based on evidence.

Cukai Vape dan Industri Rokok Elektrik di Indonesia

Konsumsi vape atau rokok elektrik saat ini merupakan bagian dari keseharian banyak orang di seluruh dunia, termasuk juga di Indonesia. Kita, khususnya yang tinggal di wilayah urban dan perkotaan, dengan mudah bisa menemukan berbagai pengguna vape, dan juga toko-toko yang menjual berbagai produk rokok elektrik dengan berbagai varian merek dan model.

Fenomena banyaknya pengguna vape ini juga membawa pengaruh terhadap industri rokok elektrik di Indonesia. Saat ini misalnya, sudah ada sekitar 100.000 pekerja yang bekerja di industri vape dan rokok elektrik. Angka ini tentu merupakan jumlah yang tidak kecil, dan sangat layak untuk diperhatikan oleh para pembuat kebijakan, khususnya yang ingin meregulasi sektor industri tersebut (tribunnews.com, 13/6/2022).

Ada berbagai hal yang menjadi alasan para konsumen untuk mengkonsumsi dan menggunakan produk-produk vape. Salah satu alasan yang umum adalah, banyak para pengguna vape yang sebelumnya perokok aktif. Mereka menggunakan vape karena harganya yang lebih murah, dan juga karena kandungan vape yang lebih tidak berbahaya bila dibandingkan dengan rokok konvensional yang dibakar. Salah satu indikator yang dirasakan oleh beberapa konsumen setelah mereka berpindah dari konsumsi rokok menjadi vape adalah, mereka merasakan nafas yang lebih lega (tribunnews.com, 26/10/2022).

Vape atau rokok elektrik sebagai produk yang jauh lebih tidak berbahaya bila dibandingkan dengan rokok konvensional yang dibakar merupakan informasi yang didapatkan dari laporan lembaga-lemabga kesehatan internasional. 

Salah satunya adalah lembaga kesehatan publik asal Inggris, Public Health England (PHE), yang pada tahun 2015 lalu mengeluarkan laporan bahwa vape atau rokok elektrik merupakan produk yang 95% jauh lebih tidak berbahaya bila dibandingkan dengan rokok konvensional yang dibakar (gov.uk, 19/8/2015).

Hal ini dikarenakan, vape atau rokok elektrik tidak menghasilkan tar dan juga karbon monoksida, yang merupakan dua elemen paling berbahaya dari rokok konvensional yang dibakar. Oleh karena itu, para perokok yang biasanya mengkonsumsi rokok konvensional yang dibakar bisa menjadikan rokok elektirk atau vape sebagai alat untuk membantu mereka berhenti merokok (nhs.uk, 10/10/2022).

Sangat penting untuk dicatat bahwa, laporan dari PHE tersebut bukan berarti menyatakan bahwa vape atau rokok elektrik merupakan produk yang aman 100%. Seseorang yang sebelumnya tidak merokok memang akan jauh lebih baik bila mereka tidak menggunakan vape. Tetapi, bagi mereka yang sudah terlanjur menjadi perokok aktif dan mengalami kecanduan terhadap produk yang sangat berbahaya tersebut, vape merupakan produk yang sangat cocok untuk digunakan agar mereka bisa berhenti merokok.

Sudah menjadi rahasia umum bahwa, Indonesia merupakan salah satu negara dengan jumlah populasi perokok aktif terbesar di dunia. Pada tahun 2021 lalu misalnya, terdapat sekitar 69,1 juta penduduk Indonesia yang menjadi perokok aktif. Hal ini belum lagi para perokok pasif yang menghisap asap rokok di ruang-ruang publik (dinkes.jakarta.go.id, 3/6/2022).

Hal ini tentu merupakan hal yang sangat berbahaya dan sangat penitng untuk diatasi. Kita yang menjadi perokok aktif tentu mengetahui bahwa berhenti merokok merupakan hal yang tidak mudah. Untuk itu, adanya produk yang jauh lebih tidak berbahaya, seperti vape atau rokok elektrik, merupakan sesuatu yang cukup positif, dan bisa dimanfaatkan untuk membantu mereka yang saat ini menjadi konsumen rokok setiap hari selama bertahun-tahun.

Namun, saat ini, sepertinya menggunakan rokok elektrik atau vape sebagai produk yang bisa membantu perokok untuk berhenti merokok bukan hal yang menjadi perhatian para regulator dan pembuat kebijakan di Indonesia. Salah satunya adalah, beberapa waktu lalu misalnya, pemerintah memutuskan untuk meningkatan cukai rokok sebesar 15% per tahun selma 5 tahun dari tahun 2023 mendatang sampai tahun 2027 (cnbcindonesia.com, 4/11/2022).

Kebijakan ini sendiri mendapatkan keberatan bukan hanya dari para pelaku usaha industri rokok elektrik, namun juga dari pihak konsumen. Hal ini akan memberikan beban lebih kepada para perokok yang ingin menggunakan produk lain yang bisa membantu mereka berhenti merokok, karena harganya yang akan naik, khususnya para perokok yang termasuk dalam golongan ekonomi menengah ke bawah (tribunnews.com, 26/10/2022).

Selain itu, hal lain yang juga tidak kalah penting untuk diperhatikan bahwa, industri vape di Indonesia didominasi oleh para pelaku usaha mikro, kecil, dan menengah. Hal ini tentu sangat berbeda dengan industri rokok konvensional di Indonesia, yang saat ini didominasi oleh banyak perusahaan konglomerat besar (vapemagz.co.id, 17/9/2020).

Untuk itu, sangat penting bagi para pembuat kebijakan di Indonesia agar tidak membuat regulasi yang kontraproduktif terkait dengan upaya menanggulangi jumlah perokok yang ada di Indonesia. Inggris misalnya, merupakan salah satu negara yang secara resmi sudah memiliki kerangka kebijakan untuk menggunakan vape sebagai salah satu alat bagi para perokok untuk berhenti merokok (nhs.uk, 10/10/2022).

Semoga, kita bisa belajar dari negara-negara lain yang sudah memiliki kerangka kebijakan yang berfokus pada harm reduction seperti Inggris. Dengan demikian, diharapkan populasi perokok aktif di Indonesia dapat semakin berkurang drastis dari waktu ke waktu.

Originally published here

A Critique of ‘Can Anti-Vaping Policies Curb Drinking Externalities?: Evidence From E-Cigarette Taxation and Traffic Fatalities’

Written by Sinclair Davidson

Recently The Economist published a report into a study that investigated vaping and taxation. The Economist reported the main conclusion of the study as being:

The study found that increasing ecigarette taxes reduces this, too. A $1 rise in ecigarette taxes brings    a 10-14% decline in the number of alcohol related traffic deaths per 100,000 among 16 to 20 year olds.

That seems to be a very impressive result. Yet, as always with public health related research, it should not be taken at face value. While The Economist itself does not provide any critique of the underlaying study, it does caution against the obvious policy conclusions that appear to follow from the study.

The study, ‘Can Anti-Vaping Policies Curb Drinking Externalities?: Evidence From E-Cigarette Taxation and Traffic Fatalities’ forms part of the Center For Health Economics And Policy Studies working paper series at San Diego State University and can be found at their website. It is also available at the NBER website and the SSRN website. At this time, the paper has not been published in an academic journal nor does it appear to have been subject to formal peer-review. It has very likely been workshopped and informally reviewed by the author’s colleagues and friends.

The paper itself has 5 co-authors. All of the authors are economists and identify as being labor economists and health economists. While the paper itself deploys the language of economics – the phrase ‘externality’ in the title and frequent mentions of ‘spillovers’ in the text – style of the paper is very much in the public health tradition. For example, there is no formal (or even informal) model to guide our interpretation of the empirical results. There are no hypotheses set out linking the empirical results to any model, definitions are vague and appear to subtly vary over the paper, summary statistics are not fully reported, the results of empirical estimations are not fully reported – for example, no goodness of fit statistics are reported at all – and, finally strong policy conclusions are reached that are not consistent with the evidence that has been produced. 

As with many of the papers we see in public health, there is a combination of the obvious, non-sequitur, and leaps of faith that combines with overly complex econometric technique that allows the authors to draw conclusions that are not fully supported by theory or data.

What is the purpose of this paper?

In the abstract, we are told:

This paper is the first to explore the spillover effects of e-cigarette taxes on teenage drinking and alcohol-related traffic fatalities.

Then in the introduction (pg.4), we are told:

This study is the first to study the effects of ENDS [electronic nicotine device systems] taxes on teenage and young adult drinking and alcohol-related traffic fatalities.

In the conclusion (pg. 28), we are told:

This study offers the first causal evidence on the impact of ENDS taxes on teen alcohol misuse and alcohol-related traffic fatalities.

So the authors claim to be investigating the relationship between taxation on vaping products and teen (or youth or young adult) consumption of alcohol and traffic fatalities. 

What does the paper claim to find?

From the introduction, we are told:

  • ‘we confirm that ENDS taxation reduces teen ENDS use, a one-dollar increase in ENDS taxes reduces teen vaping by 5.4 percentage points (or approximately 24 percent), a substantial effect.’
  • ‘we find that a one-dollar increase in ENDS taxes leads to a 1-to-2 percentage point reduction in the probability of teenage and young adult binge drinking.’
  • ‘Our results indicate that a one-dollar increase in ENDS taxes results in a 0.4 to 0.6 decline in the number of alcohol-related traffic fatalities per 100,000 16-to-20-year-olds in a treated state-year.’

It is this latter result that The Economist reports on. This result is also the ‘externality’ that is found in the title of the paper. 

To be complete, what does the paper not find?

  • ‘We find little evidence that alcohol use among those ages 21-and-older are affected by ENDS taxes.’
  • ‘We find no evidence that ENDS taxes are related to teenage traffic fatalities that do not involve alcohol … .’

This latter point is very important – the story being told in the paper relates to the social cost of alcohol. It is alcohol in this story that contributes to traffic fatalities – not vaping, or even smoking, for that matter. Now it is true that some individuals may consume both alcohol and nicotine. Yet many consume neither, or just one of the two. The story being told in this paper is that government mandated efforts to reduce (even suppress) the incidence of vaping via taxation has the effect of also reducing alcohol consumption and, by consequence, traffic fatalities for individuals aged between 16 and 20 years old – but not for individuals over the age of 20. 

This result is so specific that it seems spurious. 

This result is also not replicated in the existing literature. Vaping is a somewhat recent innovation to the consumption of nicotine. Historically individuals have accessed nicotine via combustible cigarettes, cigars, pipes and the like. Governments have tended to tax combustible nicotine products and attempt to reduce (or suppress) consumption of these products. The authors of the paper do not report any result demonstrating an externality (or spillover) from tobacco taxation resulting in reduced alcohol consumption and consequently fewer road fatalities. 

By contrast, however, they do point to a study by Adams and Cotti (2008): 

… we observe an increase in fatal accidents involving alcohol following bans on smoking in bars that is not observed in places without bans. Although an increased accident risk might seem surprising at first, two strands of literature on consumer behavior suggest potential explanations — smokers driving longer distances to a bordering jurisdiction that allows smoking in bars and smokers driving longer distances within their jurisdiction to bars that still allow smoking, perhaps through non-compliance or outdoor seating.

It must be emphasised, the notion that the increased taxation of vaping will result in fewer traffic fatalities due to reduced alcohol influenced driving is a new, and unique, result in the policy literature.

Finally, it must be pointed out that the authors make a claim that they are performing a general equilibrium analysis. Three times they make the claim:

At page 4:

Understanding the general equilibrium effects of public health policies targeting ENDS use is necessary to document the full costs and benefits to society.

At page 28:

… in order to provide a more complete understanding of general equilibrium effects of public health policies targeting ENDS.

At page 31:

Given that ENDS taxation, and optimal ENDS policy more generally, is contentious and ongoing, considering general equilibrium effects is essential.

To be very clear – the authors simply do not provide a general equilibrium analysis of ENDS taxation. They perform a patial equilibrium analysis looking at the impact of taxation on vaping and then attempt to link that analysis to alcohol consumption and road fatalities. A general equilibrium analyses would have to, at least, incorporate substitution effects between vaping and combustible nicotine products and investigate the various (private and social) costs and benefits associated with policy choices. To be fair, the authors do indicate that increased taxes on vaping does result in increased consumption of combustible nicotine products but that insight is not incorporated into their empirical analysis. 

Is there a theoretical basis for the paper’s findings?

The authors, at page 4, offer this possible explanation:

If the adoption of ENDS taxes causes a sizable reduction in the number of ENDS users, such a policy shock could generate important changes in alcohol use, which may include drinking-related externalities with substantial social costs.

That statement is some general, and so vague, that it is difficult to dispute it. Yet we are never told what this statement could possibly mean. For example:

  • It could mean that high levels of vaping taxation results in less vaping and less drinking.
  • It could mean that high levels of vaping taxation results in the same amount of vaping, but less drinking. 
  • It could mean that high levels of vaping taxation results in less vaping and more drinking.

The latter two possible meanings could be explained by a budget constraint – vaping and alcohol are consumed subject to a budget constraint and if one form of consumption becomes more expensive individuals substitute away from the more expensive activity to the less expensive activity. Or it could be that some individuals prefer, say, vaping to alcohol and when vaping becomes relatively more expensive they cut back on alcohol consumption to maintain their desired level of vaping.

The study simply does not explore these possibilities. We are informed that the results imply the very first possibility above. Vaping and alcohol consumption for 16 – 20 year olds are complements and the results show that increased taxation results in both less vaping and less alcohol consumption. 

Empirical Strategy

The paper combines data from 5 databases. Four of the five databases contain individual data as to the consumption of alcohol and nicotine for various groups and ages of respondents. The fifth database contains  traffic fatality data for the US by state and year. Being economists the authors estimate various sophisticated regression models and report robustness tests. While the paper is silent on the package used to estimate the regressions it is very likely to be Stata and a similar package and there is no doubt that the regressions have be correctly estimated.

There are problems, however, with the data that has been used in the regressions and in the specification of the equations. As is often the case, so inferences have to be made at either the 5% confidence level or even the 10% confidence level. In one instance the authors are reduced to telling us that the sign is in the correct direction.

A challenge with many public health research projects is that the data are collected from secondary sources and do not neatly match the purpose the researchers wish to apply it to. Furthermore control variables need to be applied – sometimes at higher levels of aggregation than the actual data. For example, in this study individual data as to alcohol consumption and vaping consumption is collected. While the paper suggests that this is done over the period 2003 – 2019, in fact vaping data are only collected after 2013. 

The questions relating to alcohol use are very broad. Any person who had at least one drink in the past 30 days is defined as being an alcohol user. Given that we are told that (some) surveys are distributed between January and June that means that anyone having had a drink over Christmas and New Year is not only a drinker but a multiple ‘offender’. As far as I can tell the regressions do not control for when the data was collected. 

They also include data bases that collects information about adult usage of alcohol and vaping. It is not clear why they do this, given that the study is about teenage drinking, vaping taxation, and fatalities. 

In the regression analysis they include control variables such as state based policy variables (at a high level of aggregation) and individual characteristics such as age, ethnicity, grade (surely highly correlated with age), sex, and in some specifications educational attainment. What they do not include are any indicators of a propensity for risky behaviour, part-time employment or some other source of income, whether or not they hold a drivers licence, or have access to a motor vehicle. In particular they do not control for whether the individual lives in a city or rural area (presumably having less access to various forms of public transport). Driving ages vary across the US by state and no attempt has been made to include this variable in the analysis. It is true that state based control variables are included in the analysis, but those variables are doing a lot work.

It is only the final dataset that directly addresses the research question that the authors claim to be investigating. 

Irrelevant Results

All of this data is used to demonstrate that higher levels of vaping taxation results in lower levels of vaping. Those results are shown in table 1. This is unsurprising. Demand curves slope down and this is how the world is meant to work.

In table 2 we see the impact that vaping taxation has on alcohol consumption. In the first panel we see there is no statistically significant relationship between ‘any alcohol consumption’ and the taxation of vaping. In the second and third panel we see that there is a statistically significant negative relationship between the number of drinks being consumed and, at least, one binge drinking incident and the taxation of vaping. This result could be consistent with a number of possible explanations, however, we cannot draw any serious conclusion from these results because the authors have not controlled for actual vaping in these results. The regression results in table 2 have a very serious omission – the lack of control for respondent vaping. 

The results in the final panel of table 2 relate to multiple binge drinking events. The author’s preferred specification is only statistically significant at the 10% level and is not robust to changes in the control variables used in the regression. 

Tables 3 and 4 contain robustness tests using a different regression analysis. Table 3 in particular shows clear negative relationships between alcohol consumption and vaping taxation. It, however, also suffers from the omitted variable bias that we saw in table 2.

In table 5, the authors investigate the overlap between those individuals who both vape and binge drink. While this group of individuals – and their propensity to get involved in traffic fatalities – is the very group that the authors claim to be investigating, very little shared about them. For example, we only discover on page 30 that 40% of teen vapers also binge drink. From the summary statistics we discover that 19.7% of teens (in the state-based sample) vape. That suggests that 7.9% of teens both vape and binge drink. While that may seem to be a high number, 19.9% of teens were classified as binge drinkers, so it would appear that 12% on teens binge drink, but do not vape. 

Table 5 is a lost opportunity. By including vaping in the dependent variable (a binary indicator) and not as a independent variable it reduces the ability for readers to form any firm views on the actualy dynamics in the data.

Tables 7 and 8 add other (adult) age groups into the mix. The results are age distributed – there are different effects for younger consumers than for older consumers. Given the stated research question, the results here are not interesting.

What is interesting are the results in table 6. Here the authors segment their data by sex, age, and ethnicity. A vaping tax reduces the number of drinks consumed by white males under the age of 17. At the 1% level of significance vaping taxes reduce binge drinking for 17 – 18 year olds, Hispanics and Other. Similarly at the 1% significance level a vaping tax reduces multiple instances of binge drinking for people of colour (Black, Hispanic, and Other). While public health academics may welcome results such as this, the fact is that the lack of consistency in the results undermines any confidence we can place in those results. It is very likely that random variation in the data is driving the random variations in the results. 

Getting to the Main Result

Table 9 contains results that address the research question that the authors claim to be answering. The results are not as promising as advertised. In this table the authors deploy data from the Fatality Analysis Reporting System (FARS). This data set contains state by state data on traffic fatalities. The authors extract the following information from the data set: ‘Total Traffic Fatalities, Traffic Fatalities with Driver BAC > 0, Traffic Fatalities with Driver BAC > 0.1, Traffic Fatalities with Driver BAC = 0 …’.

The authors claim that they have used the natural log of the ‘the age-specific traffic fatality rate (number of traffic fatalities per 100,000 population) in state s and year t’ as the dependent variable in a regression that includes vaping taxation and various state-based control variables. The authors do not explain why the have taken the natural log of the fatality rate. They also claim that some instances of a zero fatality rate as occurred and they have corrected for this by substituting the natural log of 1 (i.e. zero) in the regression. However, to my mind this suggests a data error in the analysis – it is not clear why any state in the US would have zero road fatalities in any of the age groups the authors claim to include in their analysis (16 – 20, 21 – 39, 40 and older). In the very instance the underlaying analysis is suspect.

There is a further problem with the dependent variable.

Consider how the authors describe their finding:

From the Abstract and again in the introduction:

… a 0.4 to 0.6 decline in the number of alcohol-related traffic fatalities per 100,000 16-to-20-year-olds in a treated state-year.

From page 15:

We focus on the period from 2003-2019 and generate a state-by-year panel of traffic fatalities for those ages 18-to-20, ages 21-to-39, and 40-and-older. Given our interest in traffic fatalities involving alcohol, we make use of information collected on Blood Alcohol Content (BAC) of the driver as well as the timing of the accident given that the alcohol-related fatalities frequently occur on nights and weekends.

At page 26, they describe the results in table 9 as follows:

  • ‘Table 9 presents estimates of the effects of ENDS taxes on traffic fatalities among 16-to-20-year-olds, generated from equation (4).’
  • First, we find that ENDS taxes are essentially unrelated to total traffic fatalities among 16-to-20-year-olds …
  • ‘…our results show consistent evidence of an ENDS tax-induced decline in alcohol-involved traffic fatalities.’

At page 27:

  • ‘… results imply an approximately 5-to-9 percent decline in alcohol involved traffic fatalities among 16-to-20-year-olds.’

It is very clear that they are describing fatalities amongst an age cohort (in this case 16 – 20). They are not describing the age of the driver, but rather the age of the people killed in the incident. 

By contrast also on page 15:

For traffic fatalities where the BAC of the driver is reported, the rate of traffic fatalities involving 18-to-20-year-old drivers with a BAC > 0 was 4.5 per 100,000 population. For those ages 21-to-39 and 40-and-older, the numbers are 5.9 and 2.5, respectively.

This is actually the variable that the authors should be using. Drivers aged 16 – 20 who have a BAC > 0. Yet, even here, they report the data for drivers aged 18 – 20. To be fair, this may be a typo. All the discussion and description – apart from this one instance – suggests that the authors have used fatality rate by age group as their dependent variable, not driver involved in a fatality aged 16 – 20. 

It is very likely that the authors have mis-specified their dependent variable of interest. The chain of causation that they want to demonstrate is that vaping taxation results in lower alcohol consumption amongst 16 – 20 year olds who then are less likely to cause traffic fatalities by drink driving. As it stands they are reporting results that demonstrate that vaping taxes lead to lower levels of alcohol consumption that result in fewer 16 – 20 year olds dying in traffic incidents where the driver of the vehicle is under the influence of alcohol but may not be aged 16 – 20. What makes this result even more problematic is that the authors demonstrate the effect they report only applies the individuals aged 16 – 20.  

Given this analysis it is very likely that the conclusions in this paper are based on a spurious regression.

Rokok Elektrik dan Miskonsepsinya

Rokok elektrik atau vape saat ini merupakan salah satu produk yang menjadi bagian keseharian yang tidak bisa dilepaskan dari jutaan orang di seluruh dunia, termasuk juga tentunya di Indonesia. Di berbagai tempat, khususnya di wilayah perkotaan, kita bisa dengan mudah menemukan berbagai pengguna vape, dan juga berbagai pertokoan yang menjual produk-produk rokok elektrik yang sangat beragam.

Semakin banyaknya konsumen yang memilih untuk mengkonsumsi vape atau rokok elektrik ini tentu disebabkan oleh berbagai hal. Setiap orang tentu memiliki alasan yang berbeda-beda mengenai mengapa mereka menggunakan vape, mulai dari harganya yang secara umum lebih murah dibandingkan dengan rokok konvensional, pilihan rasa yang lebih beragam, dan juga untuk membantu mereka mengurangi konsumsi rokok konvensional yang dibakar, yang bisa menimbulkan berbagai penyakit kronis.

Di sisi lain, ada juga sebagian kalangan yang memiliki sikap kritis dalam menanggapi semakin meningkatnya pengguna vape atau rokok elektrik yang ada di Indonesia. Mereka berpandangan bahwa vape merupakan produk yang sangat berbahaya, sama seperti rokok konvensional yang dibakar.

Padahal, sudah ada laporan yang dikeluarkan oleh berbagai lembaga kesehatan internasional yang menyatakan bahwa, vape atau rokok elektrik merupakan produk yang jauh lebih aman bila dibandingkan dengan rokok konvensional yang dibakar. Salah satu dari lembaga kesehatan yang telah mengeluarkan laporan tersebut adalah lembaga kesehatan publik asal Britania Raya, Public Health England (PHE). PHE dalam laporannya menyatakan bahwa vape atau rokok elektrik merupakan produk yang 95% jauh lebih tidak berbahaya bila dibandingkan dengan rokok konvensional (theguardian.com, 28/12/2018).

Oleh karena itu, untuk melihat fenomena tersebut secara lebih dalam, beberapa waktu lalu, lembaga advokasi konsumen internasional, Consumer Choice Center (CCC), melakukan riset mengenai persepsi masyarakat terkait dengan kebijakan harm reduction produk-produk tembakau, khususnya rokok konvensional yang dibakar. Penelitian itu sendiri dilakukan di dua negara Eropa, yakni Jerman dan Prancis.

Meskipun sudah ada laporan yang dikeluarkan oleh lembaga kesehatan publik dari berbagai negara bahwa vape atau rokok elektrik jauh lebih tidak berbahaya dibandingkan dengan rokok konvensional yang dibakar, tetapi masih banyak miskonsepsi yang diyakini oleh banyak orang. Hal ini bisa dilihat dari hasil laporan yang dilakukan oleh CCC.

Berdasarkan riset yang dilakukan oleh CCC misalnya, di Jerman, hanya ada 3 dari 15 dokter yang pernah mendengar dan mengetahui istilah harm reduction untuk mengurangi dampak buruk dari rokok. Oleh karena itu tidak mengherankan bahwa, sebagian besar dokter di Jerman tidak menganggap bahwa produk-produk vape atau rokok elektrik sebagai alat yang bisa digunakan untuk program harm reduction (consumerchoicecenter.org, 2022).

Sebagai catatan, harm reduction sendiri merupakan serangkaian kebijakan kesehatan publik yang dirancang dengan tujuan untuk mengurangi dampak negatif dari perilaku sosial tertentu. Hal ini mencakup berbagai perilaku, seperti konsumsi rokok, kegiatan seksual yang beresiko, dan lain sebagainya.

Kembali ke penelitian yang dilakukan oleh CCC, hal ini cukup berbeda dari hasil penelitian yang ada di Prancis. Di negara tempat Menara Eiffel tersebut, sebagian besar dokter pernah mendengar dan mengetahui istilah harm reduction, dan menganggap bahwa vape atau rokok elektrik bisa digunakan sebagai alat harm reduction.

Hasil penelitian lainna, ditembukan bahwa 33% perokok di Prancis dan 43% perokok di Jerman menganggap bahwa rokok elektrik memiliki bahaya yang sama atau bahkan lebih berbahaya dari rokok konvensional yang dibakar. Selain itu 69% perokok di Prancis dan 74% perokok di Jerman menganggap nikotin dapat menyebabkan kanker.

Hal ini adalah pandangan yang sangat keliru, karena nikotin dalam rokok merupakan kandungan yang menyebabkan ketagihan, namun nikotin tidak menyebabkan kanker. Ada berbagai terapi berbasis nikotin yang aman yang disarankan oleh dokter untuk para perokok yang ingin berhenti merokok (cancerresearchuk.org, 24/3/2021),

Adanya miskonsepsi tersebut juga menimbulkan dampak yang negatif dan membuat para perokok di kedua negara tersebut menjadi lebih sulit untuk menghilangkan kebiasaannya yang sangat berbahaya tersebut. Berdasarkan riset yang dilakukan CCC misalnya, 29% perokok di Prancis dan 45% perokok di Jerman tidak pernah mendapatkan masukan dari dokter tentang bagaimana langkah efektif yang bisa mereka lakukan untuk berhenti merokok.

Dari penelitian CCC di atas, meskipun dilakukan di dua negara Eropa, ada hal yang bisa ditarik dan memiliki relevansi dengan fenomena yang terjadi di Indonesia. Di Indonesia sendiri, miskonsepsi mengenai rokok elektrik merupakan sesuatu yang sangat umum. Beberapa waktu lalu misalnya, tidak sedikit pekerja medis misalnya yang mengadvokasi agar pemerintah melarang seluruh produk vape yang ada di Indonesia (cnnindonesia.com, 24/9/2019).

Sebagai penutup, adanya miskonsepsi mengenai produk-produk vape dan juga kegunannya sebagai alat harm reduction bagi para perokok tentu akan sangat merugikan publik, khususnya mereka yang sudah kecanduan dengan rokok dan memiliki keinginan untuk berhenti. Hal ini semakin berbahaya terutama di negara dengan tingkat perokok yang sangat tinggi seperti di Indonesia. Untuk itu, adanya kampanye mengenai pentingnya produk-produk tembakau alternatif seperti rokok elektrik untuk alat harm reduction merupakan sesuatu yang sangat penting, agar semakin banyak orang-orang yang bisa terbantu untuk mereka berhenti merokok.

Originally published here

CCC supports MOH to conduct full re-assessment on Tobacco Bill

THE Consumer Choice Centre (CCC) which represents consumers in over 100 countries across the globe has commended newly minted Health Minister Dr Zaliha Mustafa for taking the right measure to re-assess the Tobacco Bill.

Recently Dr Zaliha said the proposed Tobacco and Smoking Products Control Bill 2022 will be reviewed and re-evaluated before a decision is being made. The PKR-Pakatan Harapan (PH) MP for Sekijang is spot on for mentioning that implementation of any key policy must be pursued gradually or on a step-by-step basis and not drastically.

Concurring with the decision of Dr Zaliha, CCC Malaysia associate Tarmizi Anuwar said some of the proposed measures which include the Generational End Game (GEG) policy is too extreme and has created a lot of complexity.

He also pointed out the need to differentiate tobacco products from vape given the latter’s potential as a less harmful product to help reduce the number of cigarette smokers in the country.

Read the full text here

The Real Consequences the Proposed Vaping Flavor Ban in Columbus

Columbus is considering putting an end to the sales of menthol cigarettes and flavored vapes. Although official legislation hasn’t been formally introduced, tobacco-control advocates who are drafting the proposal are claiming a ban would help decrease smoking rates amongst Black people, other groups of color, women, and LGBTQ populations.

Sadly, over 20,000 Ohioans lose their lives to cigarette smoking-related illnesses every year. Considering that studies have shown vaping to be 95% less harmful than smoking and that adults who used flavored vaping products were 2.3 times more likely to quit smoking cigarettes, ensuring that adult consumers in Columbus have access to the vaping products they prefer will ultimately lead to fewer cigarette smoking-related deaths in Ohio. 

It’s estimated that more than 5% of Ohio’s adult population uses vaping products, accounting for over 634,000 Ohioans who have switched to a healthier alternative to combustible tobacco. Banning flavored vaping products will encourage these former smokers to switch back to smoking cigarettes, and will ultimately lead to increases in smoking-related healthcare costs, which are already costing Ohioan taxpayers $1.85 billion annually.

Advocates for the ban claim that it wouldn’t outlaw flavored vaping products or menthol cigarettes within Columbus, just the sale of said products and that consumers wouldn’t be punished for buying products elsewhere and bringing them into the city. Not only would this plan greatly harm small businesses who sell vaping products, but it would also effectively set up a dangerous illicit market within Columbus where bad actors could easily take advantage of consumers by selling them unregulated faulty products which could cause serious health concerns. 

Additionally, although the flavor ban intends to help minority groups of color, the reality of setting up an illicit market is that it will further exacerbate interactions between law enforcement and consumers of these products. One of the most infamous examples of this is the tragic death of Eric Garner, who was killed by police in New York after being approached on suspicion of selling untaxed individual cigarettes. 

Implementing a ban on flavored vaping products and menthol cigarettes within Columbus will have serious unintended consequences. Instead of a ban, more tobacco harm reduction efforts must first be explored such as increasing educational outreach to specific communities as well as encouraging vapes and smoke-free tobacco products as a tool for cessation. 

Elizabeth Hicks is the U.S. Affairs Analyst and David Clement is the North American Affairs Manager with the Consumer Choice Center. 

Apa yang Bisa Kita Pelajari dari Kebijakan Vape di Filipina?

Vape atau rokok elektrik saat ini merupakan salah satu produk konsumen yang digunakan oleh jutaan orang di seluruh dunia, termasuk juga di Indonesia. Saat ini, dengan sangat mudah kita bisa menemukan berbagai orang yang menggunakan rokok elektrik di berbagai tempat, terlebih lagi bila kita tinggal di wilayah urban dan kota-kota besar.

DI negara kita sendiri, konsumsi vape atau rokok kelektrik oleh para konsumen merupakan fenomena yang kian meningkat dari tahun ke tahun. Pada tahun 2018 misalnya, diperkirakan ada sekitar 2,1 juta penduduk Indonesia yang menjadi pengguna vape. Angka tersebut meningkat di tahun 2020 menjadi 2,2 juta orang yang menjadi konsumen rokok elektrik (vapemagz.co.id, 24/1/2021).

Semakin meningkatnya pengguna vape di Indonesia tentunya memberikan dampak yang signifikan terhadap industri di sektor tersebut. Industri rokok eleektrik, atau produk-produk tembakau alternatif secara keseluruhan, yang meningkat, tentu akan memberikan lapangan kerja yang besar bagi banyak tenaga kerja di Indonesia. Saat ini, industri rokok elektrik di Indonesia setidaknya sudah berhasil menyerap 100.000 tenaga kerja di Indonesia (liputan6.com, 13/6/2022).

Akan tetapi, tidak semua pihak mengapresiasi adanya fenomena tersebut. Tidak sedikit yang berpandangan bahwa fenomena semakin meningkatnya industri vape di Indonesia merupakan hal yang sangat negatif, dan berbahaya bagi kesehatan publik. Hal ini dikarenakan, mereka menyandingkan rokok elektrik dengan rokok konvensional yang dibakar, dan memiliki dampak yang sama atau bahkan lebih berbahaya dari rokok konvensional yang dibakar.

Hal ini tentu merupakan pandangan yang kurang tepat. Berbagai lembaga kesehatan dunia telah mengeluarkan laporan yang menyatakan bahwa vape atau rokok elektrik merupakan produk yang jauh lebih tidak berbahaya bila dibandingkan dengan rokok konvensional yang dibakar. Lembaga kesehatan asal Britania Raya, Public Health England (PHE) misalnya, beberapa waktu lalu mengeluarkan laporan yang menyatakan bahwa rokok elektrik 95% lebih tidak berbahaya bila dibandingkan dengan rokok konvensional yang dibakar (theguardian.com, 28/12/2018).

Sangat penting ditekankan bahwa, menyatakan bahwa vape atau rokok elektrik 95% lebih aman bila dibandingkan dengan rokok konvensional bukan berarti bahwa vape merupakan produk yang 100% aman tanpa resiko. Hal ini berarti, tetap ada resiko kesehatan bagi konsumsi vape atau rokok elektrik, namun resiko tersebut jauh lebih kecil bila dibandingkan dengan rokok konvensional yang dibakar.

Oleh karena itu, beberapa negara di dunia telah secara resmi mengeluarkan kebijakan yang ditujukan untuk memberi insentif bagi para perokok untuk berpindah ke rokok elektrik, atau yang dikenal dengan kebijakan harm reduction. Inggris misalnya, melalui lembaga kesehatan nasional National Health Service (NHS), mendorong warga Inggris yang perokok aktif untuk berpindah ke produk rokok elektrik yang jauh lebih tidak berbahaya (nhs.uk, 29/3/2019).

Inggris tentunya bukan satu-satunya negara yang mengambil langkah tersebut. Tidak perlu jauh-jauh ke negeri tempat kelahiran Ratu Elizabeth II tersebut, negara kita sesama anggota ASEAN, Filipina, baru-baru ini juga mengeluarkan peraturan yang kurang lebih serupa. Pada bulan Januari tahun ini, lembaga legislasi FIlipina berhasil meloloskan undang-undang yang dikenal dengan nama The Vaporized Nicotine Products Regulation Act.

Salah satu aspek yang paling penting dari undang-undang tersebut adalah regulasi ini memberi jalan untuk menyusun strategi kebijakan harm reduction untuk menawarkan rokok elektrik sebagai pengganti rokok konvensional kepada para perokok. Filipina sendiri saat ini memiliki sekitar 16 juta perokok aktif yang tinggal di negara tersebut (vaping360.com, 27/7/2022).

Selain itu, undang-undang ini juga melakukan beberapa perubahan yang menerapkan regulasi yang tidak jauh berbeda antara rokok konvensional yang dibakar dan rokok elektrik. Misalnya, penyetaraan batas usia konsumsi rokok konvensional dengan rokok elektrik. Dengan demikian, akan semakin banyak orang yang memiliki opsi legal untuk mengkonsumsi produk yang jauh lebih tidak berbahaya. Akan ada pula sanksi yang diberlakukan kepada penjual yang menjual produk-produk hasil olahan tembakau kepada anak-anak di bawah usia.

Peraturan yang diberlakukan di Filipina ini merupakan hal yang cukup berbeda dengan beberapa negara ASEAN lainnya, seperti Thailand dan Singapura misalnya. Di Thailand dan Singapura, vape atau roko elektrik merupakan produk ilegal, di mana mereka yang melanggar dapat dikenakan sanksi pidana baik berupa denda maupun penjara, meskipun rokok elektrik merupakan salah satu produk yang telah digunakan oleh jutaan perokok untuk membantu mereka berhenti merokok.

Sebagai penutup, langkah kebijakan yang dilakukan oleh Filipina yang meloloskan regulasi agar para perokok bisa berpindah ke rokok elektrik yang jauh lebih tidak berbahaya merupakan hal yang bisa dipelajari oleh para pembuat kebijakan di Indonesia. Bila semakin banyak perokok yang bisa berpindah ke produk yang jauh lebih tidak berbahaya, maka dengan demikian diharapkan berbagai penyakit kronis yang melanda masyarakat juga dapat ditekan, dan akan membawa dampak yang positif terhadap kesehatan publik.

Originally published here

Widespread misinformation about vaping hurts public health

Quitting cigarettes is one of the hardest things to do, as many former and current smokers know from painful personal experience. Public health and politicians must do better to help smokers quit. 700,000 deaths per year in the EU should be enough of an incentive to make us rethink our current approach.

To effectively help smokers quit for good, three conditions must be met:

Firstly, smokers must be able to choose from as many options as possible to find out what smoking cessation method works best for them. People are different, and therefore different ways to give up smoking must be made available and affordable. For very few people (less than 4%), quitting with no help works. For a few, nicotine replacement therapy (such as nicotine gums or patches) works, and it turns out that for many people, new nicotine alternatives help them with quitting smoking once and for all. Those products range from vaping and heat-not-burn products to snus or nicotine pouches. What all these new forms have in common is that they separate nicotine consumption from the combustion of tobacco (which produces the vast majority of the toxicity of smoking), making them far less harmful than smoking cigarettes. Each one is different, each working best for each different person.

62% of smokers in France and 53% in Germany believe anti-smoking policies ignore how difficult it is to stop smoking. Clearly, smokers are not satisfied with traditional cessation methods and therefore look to vaping as a means of quitting

Secondly, we need a modern, open regulatory framework to fit these new alternatives. These new products are not the same as smoking. Hence, they must not be painted with the same regulatory brush. What we need instead is risk-based regulation. Vaping is 95% less harmful than smoking and, therefore, must not be treated the same way. Harm reduction must become a centrepiece of anti-smoking policies, like in the field of pharmaceutical drugs. Harm reduction follows practical strategies and solutions to reduce harmful consequences associated with using certain substances instead of an unrealistic `just quit´ approach. Encouraging smokers who are not able to or don’t want to quit smoking to switch to vaping is a best-case example of harm reduction.

Thirdly, smokers must have accurate information about the potential risks of different products to make decisions. The same applies to medical professionals who are working with those smokers. They need to know the facts to make a lasting difference for smokers.

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