Abstract
The Commercial Determinants of Health (CDH) have a major impact on the health of a country's population. The marketing and promotion of products and services by corporations, especially multinational businesses, can significantly impact individuals and communities, both positively and negatively. The vaping epidemic in the Philippines is an example of how commercial influences and government policies, in the context of disinformation, can exacerbate public health issues. The Philippines is facing a rising use of electronic nicotine delivery systems (ENDS) among youth. We conducted a literature review in PubMed and Google Scholar to examine the state of vaping in the Philippines and the lack of research on the health implications of the growing e-cigarette industry. We also discussed the vape bill which lapsed into law – Republic Act 11900, which regulates e-cigarettes and transfers the regulatory power from the Department of Health to the Department of Trade and Industry. We outlined a call to action on three fronts: tailoring national policies, funding research, and improving health education in the youth. Policymakers must prioritize public health gains over economic benefits and consider the impact of their decisions on future generations' health choices.
Keywords
Commercial determinants of health (CDH) play a crucial role in shaping the overall health of a country’s population. 1 Corporate entities, especially multinational businesses, and companies, have the potential to greatly impact health through their products and services. Their commercial activities, such as advertising along with the environment in which they are situated, are considered to be CDH. It is important to note that the marketing and promotion of these products can significantly impact the health of individuals and communities, both positively and negatively. Economic and government policies surrounding these activities may also have a direct impact on health.
These determinants play a significant impact on health choices, which can be a pivotal point in improving a nation's overall health literacy. 2 Smoking, for one, has been implicated as one of the risk factors for many non-communicable diseases. Health policies and laws are being developed to aid smoking cessation in the population. On the rise, however, are electronic nicotine delivery systems (ENDS) which have been dubbed as the “healthier” alternative to tobacco smoking. In light of this, we would like to present the current vaping epidemic in the Philippines as an example of how commercial influences and development of a law, in the context of disinformation, have the potential to exacerbate public health issues.
We did a thorough literature review in PubMed with the following search query: (“vaping"[MeSH Terms] OR “electronic nicotine delivery systems"[MeSH Terms] OR “smoking/cessation"[MeSH Terms]) AND "philippines"[MeSH Terms]. The aim is to pinpoint medical research on vaping in the Philippines as of March 2023. The search returned 21 articles, with only a handful of articles relevant to the Philippine vaping situation: a commentary tackling how the Philippine political landscape affects health priorities in the context of e-cigarettes, 3 a feature article on the rising problem of vaping among the Filipino youth, 4 and a descriptive correlation study in the Philippines looking at the knowledge and attitude of nursing students towards e-cigarettes. 5 Google Scholar was also thoroughly searched for studies on the Philippine e-cigarette situation. These serve to give insights as to the country’s current public health standing on this and how neighboring Southeast Asian / West Pacific countries are dealing with the vaping situation. Notably, there is a lack of primary research being done on the health consequences of the growing e-cigarette industry, especially in the Philippines. It is crucial to maintain monitoring to gather the information that can inform the development of measures and policies aimed at preventing people from starting to use e-cigarettes and providing increased support for those who want to quit tobacco smoking. 6
The Philippine Context
The World Health Organization has maintained its stance on the dangers to health brought about by e-cigarettes.7,8 The Philippines may be facing an uphill struggle in the vaping epidemic. The Global Youth Tobacco Survey (GYTS) which was done last 2019 showed that the country is facing an alarming prevalence of using ENDS among the youth. 1 in every 7 students, aged 13-15 years old, is already using e-cigarettes 9 - an age group far less than what is allowed by existing laws. In addition, the survey highlights that there is an easy accessibility for tobacco products as a whole, with 37.1% of the youth not being prevented from buying these products regardless of their age, both from stores or street vendors and as advertised in social media. 9 Health professionals on the frontlines in the country also play a crucial role in tobacco control activities. In a prevalence study done in the Visayas region, Palmes et al. found that nursing students lacked sufficient knowledge of e-cigarettes, but held a favorable stance toward not using them. 5 What is worse is that the dangers of this practice are often clouded in social media where most Filipinos derive their news from.
Social media, particularly Facebook, is widely used in the Philippines not just as a social media platform but also as a major news source and e-commerce platform. The app dominates the social media market in the country, reflected in the increasing number of Filipino users. 10 However, this is also the top social media platform for misinformation that can be exploited. 11
On July 25, 2022, the Republic Act 11900, or the Vaporized Nicotine and Non-Nicotine Products Regulation Act lapsed into a law. The new law was also described as “one of the most well-studied pieces of legislation” after having passed multiple hearings in the Philippine Congress. 12 The law aims to formally regulate e-cigarettes and provide an avenue for tobacco smokers to choose an alternative to aid them in quitting. However, while the intention is good, this law not only legitimizes the use of vaping products but also lowers the age at which these can be accessed (i.e. from 21 to 18 years old). In addition, the said law also transfers the regulatory power from the Department of Health (DOH), which is mandated to protect the health of every Filipino people, through the Food and Drug Administration (FDA), to the Department of Trade and Industry (DTI), the regulatory body for consumer products. 13 Before the law’s implementation, these products were classified as medicinal products and hence, were tightly regulated by the country’s health regulatory body to pass all quality, efficacy, and safety evaluations before they can be sold. 14 Despite calls for veto by the DOH, the bill was passed into law with most politicians favoring pro-industry policies. With these in place, it will be even easier for an average teenage Filipino to pick up the habit of vaping. This is a grim reminder to all that possible repercussions in health choices due to political decisions may be seen in the next few years. Hence, we recommend a call to action on three fronts – tailoring national policies, funding research, and improving health education in the youth.
Recommendations
National Policies - Initially, ENDS were advertised as a means to quit smoking traditional cigarettes, however, they have not received official recognition as a quitting aid. Furthermore, 1 in every 4 individuals who use ENDS has never smoked conventional cigarettes, which undermines the effect corporate advertising is exerting on public health. 15 While corporate influence in these products may be huge and a main contributing factor, national policies regulating these should also be cautious of their impact on different individuals and populations. With health being political, policymakers are called in this endeavor to contribute by prioritizing public health gains over economic benefits. 3 One example of this is the recent passing of House Bill 5532, which aims to increase excise taxes on these products to combat the youth vaping crisis. 16 Current policymakers' preferential decisions about this can impact the trajectory of an entire generation’s health choices. As the e-cigarette industry is for-profit and rapidly changing, we should always be on the lookout when public health is threatened.
Research - The most recent available prevalence study that was done nationwide was the Global Youth Tobacco Survey, 9 which was conducted in 2019 - prior to the implementation of the Vape Law. Local initiatives to assess the prevalence of e-cigarette use in the youth in the coming years must be sought, especially in the Department of Health’s research agenda. To gain a comprehensive understanding of why young people are drawn to using e-cigarettes and how their availability may play a role, it is important to highlight both quantitative research, such as studies on knowledge, attitudes, and practices, as well as qualitative and mixed methods studies. These approaches offer deeper insights and explanations, providing valuable information for the development of prevention and intervention efforts.
Health Education - In this age of misinformation and disinformation in the Philippines, 17 it is imperative to equip young minds with critical thinking skills and reiterate the dangers of vaping. With a huge percentage of Filipino families getting their facts from social media, the danger of disinformation may inadvertently introduce previously non-smoker adolescents to try and start their path to nicotine addiction. In the context of the newly passed law, individuals may have the impression that despite being legitimized and regulated, these products are safe and will not cause harm to their health. Furthermore, multiple studies have already shown the initiation of e-cigarette use in adolescents is associated with the subsequent use of tobacco products in later life. 18 This may propagate a vicious cycle where vaping becomes a “healthier” alternative and thus, is promoted to be used even for non-smokers. This would serve to remind us that the very measure we took to safeguard the youth through regulation by the law may ultimately prove to be our undoing. While the intention behind the vaping law may be to protect individuals, it may unintentionally lead to an increase in vaping usage over the years to come.
Local health policies must then be targeted to address cutting down vaping in young adults while maintaining options for previous smokers to quit. Thus, there is a need to safeguard the youth regarding the use of vaping products by reiterating the role parents and guardians play in their child’s choices. Through the Department of Education, improving the school curricula can also be done by collaborating with health authorities to include and highlight the dangers of vaping. Being able to decide and appraise health choices must be taught both at home and in school at a very young age in order to curb this growing epidemic. Pediatricians and primary care physicians can also be tapped to screen for ENDs during consults and provide timely prevention or cessation counseling for patients and their families. 4 In the youth where peer pressure plays a major role in their decision-making capacity, it can be utilized to start a ripple effect from individuals to groups and their respective communities. To strengthen this, community-based health literacy interventions can be explored to further determine context-specific determinants that cause vaping in the youth, may it be familial or peer influence, product accessibility, or false information. We strongly advocate for the implementation of multi-sectoral strategies to promote health literacy among young people, as this will equip them with the knowledge and skills necessary to make informed, healthy decisions for themselves and future generations. Improving health literacy, with regards to electronic cigarettes in particular, in the Philippines may be a challenging task, but investing in the education and empowerment of the youth holds great promise for the future.
Conclusion
Recommendations for a call to action protecting the youth include the development of national policies that prioritize public health gains over economic benefits, increased funding for research on the health implications of the e-cigarette industry, and improved health education. It is important that the public and policymakers alike are aware of the dangers posed by commercial determinants of health.