What We Should Know About Vaping?

Smoking is a known health issue. Evidence has shown that besides the nicotine which is responsible for the addiction to smoking, each cigarette stick contains over 4000 chemicals which are toxicants and carcinogen (can cause cancer). Smoking has been related with many diseases like COPD, ischaemic heart disease cancer of the lungs, prostate, breast and in asthmatics it worsens the condition. All these effects are also seen amongst the second hand smoke ii the people who breathes in the smokes produced by the people smoking around them.
Smoking evolves from burning tobacco which is wrapped with a leaf (rokok daun) to what is available now. Similarly interventions and activities to quit smoking evolve. From counselling and behaviour therapy to NRT (Nicotine replacement therapy) and pharmacotherapy (eg: varenicline). Along the way E cigarettes has been produced and it too evolves from appearing exactly like a cigarette stick to the present e cigarette which is better known as Vape.
Why E cigarette or Vape?
Majority uses E cigarettes because they:
1. Want to stop or quit smoking
2. Feel Vaping or e cigarette is safer
3. Believe Less addictive
4. Want to flow with the currents trend
5. Have more freedom to use in public places
6. Think it has Less effect to people around them (second hand vapers)
7. Believe it is Cheaper,
And for various other reasons like for fun, it’s the technology and youngsters used it out of curiosity!
Facts on vaping.
A. Is it true that Vaping or smoking e cigarette is safe
o Vaping is still not safe, even though it contains lesser harmful chemicals (toxicants & carcinogens) compared to conventional cigarettes. The prophylene glycol which is responsible in producing the vapours, will be converted to acetaldehyde (ex: formaldehyde which is used to preserve dead body) when burnt. There are studies on industrial use of propylene glycol and exposure to theatre fog (produced from prophylene glycol) that show negative health effects. These effects include throat and eye irritation, cough, mild airway obstruction, headache, and dizziness. So, inhalation of this humectant is not as safe as most people think.
o The problems with the labs studies that examined the presence of toxicants & carcinogens in e-cigarettes only tested for known toxicants and carcinogens of conventional cigarettes. Other impurities or by-products of heating e-juices are not known.
o You can become a drug addict by vaping! There has been a recent news about the juices has drugs added to it to increase its effects when used. You may start vaping to quit smoking or out of curiosity but end up a drug addict.

B. People can get addicted to vaping
As mentioned earlier the chemical responsible for addiction is nicotine. It has been found that even the e juice labelled as nicotine free contain certain amount of nicotine. Studies have shown that people do not use vape forever. Majority quit vape. They end up smoking conventional cigarettes.

C. Are people around the e cigarette vaping affected?
There are studies which show that vaping changed the air quality around them. The concentration of PAH (polycyclic aromatic hydrocarbon) increases. Another study also found an increase in serum cotinine in the ‘second hand’ vaping. Unfortunately there are no studies to confirm the long term impact of vaping to the people around them. Let’s make sure our children and spouses are not the ‘guinea pigs’ for this study.
D. What is the issue with our children and adolescents?
Adults may vape to quit smoking. However adolescents do it out of curiosity, to fit in with the peer group and to follow the trends. This will not be for long until they become dependent on nicotine and later become chain smoker although they might not have planned to smoke in the first place. This is actually another public health concern. Vaping can cause gateway to nicotine addiction/ smoking conventional cigarettes especially among adolescents’.
E. Can E cigarette be used to quit smoking?
o There are evidences that demonstrate ‘vaping can help smoking abstinence or cessation’. It showed that vapers had 2.2 times the chance to stop smoking conventional cigarettes for at least 6 months compared to smokers who do not vape. However, vaping still allows maintenance of nicotine addiction. Vapers still receive nicotine from e-cigarettes. Studies that examine its effectiveness as a treatment of smoking cessation (comparing with NRTs and Champix) are also lacking. So, it’s effectiveness as a treatment for smoking cessation (like nicotine replacement therapy) is still not proven. One of the possible reasons because the amount of nicotine that the vapers get from inhaling the vapours are varied, and it is quite difficult to titre down the concentration of nicotine. Even though they use the lowest concentration labelled on the bottles of e-juices, it is not guaranteed that they inhale nicotine of the stated concentration. The concentrations of nicotine are different from puff-to-puff, and across the brands and models of e-cigarettes. Furthermore, this smoking abstinence may not be sustainable as studies have shown that substantial number of vapers does relapse to smoking conventional cigarettes due to many reasons.

F. Vaping can be hazardous
The latest news on the hazards caused by vaping is the fire in a flight which developed from a vape kept in the pocket in one of the passenger. It has been reported that the device explodes while using causing injuries to the users hand and face
Ingestion of the ejuice can be fatal. It can cause nicotine toxicity. The initial symptoms are mainly due to stimulatory effects and include nausea and vomiting, excessive salivation, abdominal pain, sweating, low blood pressure, increased heart rate, tremors, headache, dizziness, muscle fasciculation and seizures. Later the depressor effect will take place where it causes low blood pressure, low hear rate, muscle weakness/paralysis, difficulty in breathing, central nervous system depression and coma
To really combat problems with nicotine addiction, it must involve all bodies, organisations, employers, and even all Malaysians to create a norm that ‘smoking or vaping is unacceptable’. For those who have chosen a wrong step in the past and already addicted to nicotine, their struggle to free themselves from this addiction should not be undermined. We have to help them to treat their nicotine addiction by ensuring that they can appreciate their risks of smoking, helping them to overcome their barriers, providing them necessary skills to change their habits and psychological dependence, and prescribing the proven effective pharmacotherapy. As majority of the smokers are in pre-contemplation stage, doctors should be trained to provide counselling for these smokers so that they want to stop smoking. Doctors should be trained to provide effective interventions for smoking cessation. Doctors should also be provided with adequate medication and non-pharmacological assistance for treating nicotine addiction. Smokers need to be assisted adequately to quit and their difficulties in the battle must be taken care and intervened as best as possible. The most important thing is we should aim for no smoking and no vaping. Smokers need to come forward to seek help and get rid of their addiction problem.
As vaping device can also be used to inhale illicit drugs openly without being notice by narcotic enforcement team and our country Malaysia is well known to have strict drug law hence any possibility of facilitating illicit drug use must be taken action seriously. In fact it was recently discovered by the ESERI, Universiti Sultan Zainal Abidin Terengganu that vape liquid studied in the laboratory also contain cannabis precursor (both synthetic and natural).
In conclusion smoking conventional cigarette and vaping are both addictive and harmful. Although the cigarette and vape industries may create great wealth to some, we must always remember, our greatest wealth is health.
Dr Salmah Nordin & Dr Hizlinda Tohid
Family Medicine Specialists Association Malaysia (FMSA)

An open letter to the Members of Parliament of Malaysia

13 November 2015


An open letter to the Members of Parliament of Malaysia

We, the undersigned medical professional bodies and non-governmental organisations, would like to register our concern regarding the increasing presence of electronic cigarettes and vaping in our society. We note with dismay the Cabinet’s rejection of the Ministry of Health’s proposal to ban the sales and use of electronic cigarettes.

1. Malaysia proudly signed and ratified the World Health Organisation’s Framework Convention on Tobacco Control (FCTC). This is a reflection of the nation’s commitment to protect present and future generations from the devastating effects of tobacco, a product that kills 6 million users annually. In Malaysia alone, eight individuals are killed daily due to tobacco and many more are affected by the significant health, social, economic and environmental costs.

2. It is a commonly held but misleading view that electronic cigarettes and vaping are safe. However, due to the lack of any form of quality control, equipment malfunction (include explosions leading to death) have been reported. The content of electronic cigarette ‘juice’ also varies depending on the manufacturer, with studies demonstrating a huge variability in toxin content and nicotine delivery. Even claims that the colourings used are safe are misleading as most consist of industry-certified food dyes, which can be safely swallowed but not necessarily safely inhaled.

3. The increasing use of electronic cigarettes, ostensibly as a smoking cessation tool, is not backed by current scientific evidence. Although the potential for harm reduction is an opportunity not to be missed, we must be careful that we are not substituting one form of addiction for another. At present, scientific evidence indicates that most individuals end up being dual users – i.e. using electronic cigarettes and tobacco at the same time. We are cognisant of the harmful effects of nicotine dependence, which is why it is a Group C Poison under the Poisons Act 1952.

4. The use of electronic cigarettes does not solve the problem of nicotine addiction. This problem is compounded by the fact that electronic cigarettes are gaining popularity amongst youth. Studies from the United States have demonstrated that children are increasingly using electronic cigarettes and that these same children are more likely to eventually smoke tobacco. In other words, the use of electronic cigarettes is a gateway to lifelong nicotine addiction.

5. It is clear that many products are targeted at younger sections of society despite claims to the contrary. Electronic cigarettes are sold with attractive colours and flavours, with marketing very similar to that employed by the tobacco industry in decades gone by. The sexualisation of the product with advertisements consisting of scantily-clad women and flavours such as ‘the taste of a virgin’ and ‘nenen’ (breast milk) also points to a worrying trend that is against the cultural norms of our beloved nation.

6. It is because of these factors that we welcome the statement by the Health Minister, Datuk Seri S Subramaniam, regarding the Ministry of Health’s long-term aim to ban electronic cigarettes. We truly believe that this move is for the benefit of our rakyat’s health. It is also in keeping with similar moves by our neighbours in the region, namely Singapore, Thailand and Brunei.

We are aware of allegations that this move is a result of lobbying by the tobacco industry, but it should be pointed out that most electronic cigarettes are manufactured by tobacco companies. Furthermore, we welcome the statements by YB Khairy Jamaluddin (Minister for Youth and Sports) and Datuk Dr Lokman Hakim, Deputy Director-General for Public Health, that a ban of electronic cigarettes should be in tandem with a ban of tobacco.

We call upon Parliament, as the most august law-making body of the land, to take the above points into consideration and to take into account the following proposals:

I. restrictions be immediately put in place for the retail sales and public use of electronic cigarettes and vaping
II. a discussion in Parliament in the foreseeable future regarding the need to implement a ban for both electronic cigarettes and tobacco
III. introduction of retail licensing for tobacco products retailers
IV. ensure that restrictions and bans are enforced rigorously without fear or favour
V. ensure that a fixed proportion of taxes and excise duties raised from tobacco sales are used exclusively for tobacco control efforts
VI. continuous increase in tobacco taxes and electronic cigarettes alongside related paraphernalia
VII. support access to smoking cessation services, including subsiding the cost for treatment. We are aware that more than 50% of current smokers in Malaysia are keen to quit, and it is our duty to help them achieve abstinence

We reiterate the point that it is misleading to say that the effects of electronic cigarettes on our health and society is minimal. We must learn from the mistakes made during the public health efforts against tobacco, in which it took decades for the true costs of tobacco to society to be made public.

The health of Malaysians today and tomorrow is too precious a commodity to be gambled. We urge the Members of Parliament from across the political spectrum to set aside their differences and support the Ministry of Health’s efforts in prioritising the health of the rakyat above all else.

Issued by:
The Malaysian Thoracic Society (MTS) on behalf of the following medical
professional bodies and non-governmental organisations:
Academy of Medicine of Malaysia Addiction Medicine Association Malaysia (AMAM)
Asia Pacific Academic Consortium for Public Health Kuala Lumpur
College of Public Health Medicine
Consumer Association of Penang (CAP)
Faculty of Medicine, Universiti Mal
Faculty of Medicine, Universiti Kebangsaan Malaysia
Faculty of Medicine, Universiti Teknologi Mara
Family Medicine Specialists Association (FMSA)
Federation of Malaysian Consumers Association (FOMCA)
Federation of Private Medical Practitioners’ Associations Malaysia (FPMPAM)
Ikatan Pengamal Perubatan dan Kesihatan Muslim Malaysia (I-Medik)
Islamic Medical Association of Malaysia (IMAM)
Islamic Renaissance Front (IRF)
Lung Foundation of Malaysia (LFM)
Malaysian Academy of Pharmacy
Malaysian Adolescent Health Association (MAHA)
Malaysian Animal-Assisted Therapy for the Disabled and Elderly Association (PETPOSITIVE)
Malaysian Association for Bronchology and Interventional Pulmonology (MABIP)
Malaysian Association of Environmental Health
Malaysian College of Physicians
Malaysian Council for Tobacco Control (MCTC)
Malaysian Association of Dental Public Health (MADPH)
Malaysian Green Lung Association
Malaysian Gynaecological Cancer Society
Malaysian Medical Association (MMA)
Malaysian Paediatric Association (MPA)
Malaysian Pharmaceutical Society (MPS)
Malaysian Psychiatric Association (MPA)
Malaysian Thoracic Society (MTS)
Malaysian Women’s Action for Tobacco Control & Health (MyWATCH)
Medical Practitioners Coalition Association of Malaysia (MPCAM)
National Cancer Society Malaysia (NCSM)
Pemuda dan Wanita Ikatan Muslimin Malaysia (ISMA)
Penang Medical Practitioners’ Society
Persatuan Belia Islam Nasional
Persatuan Doktor Pakar Kesihatan Awam Malaysia
Persatuan Pakar Perubatan Islam Malaysia (PAKAR)
Persatuan Pengguna-Pengguna Pengangkutan Awam Malaysia (4PAM)
Pertubuhan Amal Perubatan Ibnu Sina Malaysia (PAPISMA)
Pertubuhan Doktor-Doktor Islam Malaysia (PERDIM)

It’s going to be family docs first, says minister

Datuk_Dr.S.SubramaniamMALACCA: The Government is set to revive the concept and role of the family physician as the “first line” of healthcare for the people.

Health Minister Datuk Seri Dr S. Subramaniam said the approach would see patients being treated and diagnosed much earlier.

“This approach is to ensure that the people keep healthy by seeing their family physicians regularly and not when they are already seriously ill,” he told reporters after a two-day conference here yesterday with stakeholders on the ministry’s future direction over the next four years.

Dr Subramaniam said the decision to revive the concept was decided at the conference.

The Government, he said, would empower health clinics nationwide to realise the practice of family physicians.

“Higher allocations would be given to existing health clinics for them to be better equipped.

“Appropriate training on family medical healthcare will also be given soon for doctors and other staff,” he added.

Dr Subramaniam said the practice of having family physicians used to be the norm in the old days, where every member of a family were seen by a family doctor who was familiar with their medical history.

The ministry, he said, was also looking into a proper bridging mechanism to utilise all facilities available in the public and private healthcare system.

Becoming a Family Medicine Specialist in Malaysia

Dr FerariWritten by Dr Far Ari

Lately a few friends have approached me with regards to becoming a Family Medicine Specialist in Malaysia. I hope the information here will be beneficial to all

Although General Practitioners (GP) have been around for the longest time in Malaysia however, the recognition and training of Family Medicine Specialist (FMS) in Malaysia is a relatively new and began in 2003 or so.

The rules with regards to opening a private GP clinic in Malaysia has not yet changed although there has been some talks and attempts to ensure that future GPs will have some form of accredited training prior to working in General Practice. On the ground level, more and more new GPs are taking their own initiative to receive training in the field of General Practice.

I guess this is due to various reasons. With abundance of MBBS graduates being churned out per year…doctors are becoming aware of their need to specialise and to attain a postgraduate qualification. Modern medicine is rapidly changing. Research in the field of medicine is growing ever so fast and there are more available grants. Even I am involved in research…so that says something!

Patients are also becoming more health concious and aware of the new advances in medicine. The concept of patients ‘blindly’ following doctor’s instructions are slowly shifting to a more ‘patient centred approach’. Hence, there is an increase challenge for doctors to keep up with new medications, new treatments and new approaches in communicating to patients.

It is no longer acceptable for doctors to practice convenient medicine and continue in their management of patients based on their 30 years experience. Experience is no doubt exceptionally valuable and nothing can replace a highly experienced doctor. However, the educational component, structured learning and mentoring process of the postgraduate training is vital in ensuring a high clinical standard of all doctors and create a passion for life long learning. The exposure to different specialties is extremely valuable for GPs in order to equip them with the ability to diagnose and manage multiple complaints of various systems and origins.

To become an FMS or primary care specialist in Malaysia you need to have a postgraduate degree in either MMed Family Medicine, FRACGP or MRCGP.

MRCGP training is in the UK and it is a structured 3-year training programme. Although there is MRCGP [International] which candidates can sit for in various countries including Brunei, Sri Lanka and others. However, there is no structured training available, it maybe expensive and the passing rate is relatively low.

Candidates may enter the Diploma in Family Medicine (DFM) training conducted by Academy of Family Physician Malaysia (AFPM). The DFM is a 2-year part time structured course with examinations. After completing the 2-year DFM candidates may opt to continue with the Vocational Training Scheme (VTS) and sit for the MAFP/FRACGP which is a Malaysian/ Australian General Practice professional examinations to become a member of the Australian Royal College of General Pracitioners. At present, candidates who sit for this exams may also work in Australia.

Candidates may choose to join the Masters in Family Medicine training which is currently offered in University Malaya (UM), University Kebangsaan Malaysia (UKM), University Sains Malaysian (USM) and University Teknologi MARA (UiTM). This is a 4-year full time structured training with research component in year 4. This is an excellent programme and suitable for those planning to go into academic, teaching and research within a University setting or to work in the MOH Health Clinics.

We are seeing more GPs even those who have been practising for many years joining the DFM programme and venturing into FRACGP. We are also seeing more applications for the Masters in Family Medicine training. I believe even without the pressure or law by the MOH the trend is for future GPs to have postgraduate training and qualification in General Practice.