The Philippines has long been burdened with tobacco-related illnesses.1 Over the past 2 decades, national legislation was enacted to address this problem. Tobacco control policies include prohibitions on public smoking and advertising, the enforcement of graphic health warning labels, and increased taxes on tobacco products. These policies were associated with significant declines in smoking among Filipino adults and adolescents.1,2 However, the increasing popularity of electronic nicotine delivery systems (ENDS) among Filipino youth may reverse this progress. Evidence indicates that youth who use ENDS may be more likely to smoke conventional cigarettes in the future.3,4
The Philippines relies on the Global Youth Tobacco Survey to monitor ENDS use in Filipino youth. From 2015 to 2019, e-cigarette use among Filipino teenagers aged 13 to 15 increased by 110%. In 2019, 14.1% of Filipino teenagers reported e-cigarette use in the past 30 days whereas 24.6% tried e-cigarettes at least once in their lifetime.5,6
National policies were introduced to combat this emerging problem. Policies set the minimum age of access at 21, banned public use and advertisements, and prohibited the sale of nonmenthol or tobacco flavors. Heavy taxation was imposed on the manufacture, importation, and distribution of ENDS. The Philippine Food and Drug Administration (FDA) was assigned regulatory oversight.7–9
The Philippine Vaporized Nicotine Products Regulation Act, also known as the Vape Bill, was signed into law on July 25, 2022. It overturns many of these policies by lowering the minimum age of access, allowing online advertising and promotional events, lifting the ban on the sale of nonmenthol/tobacco flavors, and reassigning regulatory oversight. In this paper, we examine the sociopolitical circumstances which led to the passage of the bill and discuss how the new legislation may make youth more susceptible to ENDS and tobacco use rather than protect them. By analyzing ENDS regulation in the Philippines, we hope to alert the international medical community to challenges surrounding ENDS regulation and explore steps moving forward.
What Went Wrong?
In the 2010s, tobacco control advocates in the Philippines successfully counteracted the tobacco industry and increased tobacco excise taxes through public demonstrations, media advocacy, and political lobbying.10–12 These strategies were not as successful against the Vape Bill, which was introduced during the coronavirus disease 2019 pandemic. It is possible that health professionals were overextended and overwhelmed, and the public's focus may have been elsewhere. In addition, the most recent national survey, the 2019 Global Youth Tobacco Survey, was conducted before the initiation of ENDS regulation. The lack of updated data on the ENDS use of Filipino youth made it difficult to assess the effects of the initial regulatory measures.
Easier Access for the Youth
Several measures in the Vape Bill may place youth at a higher risk of ENDS and tobacco use. The minimum age of access to ENDS decreased from 21 to 18 years old. Studies suggest that this change may facilitate the transition from e-cigarettes to conventional cigarettes because the average age at initiation of cigarette use among Filipinos is 18 to 19.1,3,4
Online advertising and promotions are now permitted. This move expands ENDS visibility and accessibility among youth despite the lack of effective online age verification strategies.13 Current forms of age verification are limited to simple methods like typing the buyer’s age or indicating via a checkbox that a buyer is 18 or older. A flavor ban for ENDS was lifted. This also increases the risk for youth because flavored e-cigarettes are highly appealing to youth and are a commonly cited reason for initiation and continued use.14
Disempowerment of Regulatory Institutions
Regulatory oversight of e-cigarettes was shifted to the Department of Trade and Industry, which is a government body that promotes economic trade. The FDA is now a consultant to the Department of Trade and Industry. With indirect rather than direct regulatory oversight, the FDA no longer controls key health aspects with respect to ENDS. This includes their registration, manufacture, importation, sale, packaging, advertising, and distribution. To justify the regulatory shift, ENDS were characterized as consumer products without health claims. This seems to contradict another measure in the bill which mandates graphic health warning labels on ENDS, similar to those on tobacco products.15 ENDS, which clearly have harmful effects on health,16 warrant the same FDA regulation as tobacco and nicotine replacement therapies.
We also highlight an attempt to possibly undermine the Philippine FDA’s credibility. Legislators from tobacco-producing areas cited the FDA for acting unlawfully after they accepted a grant from Bloomberg Philanthropies to strengthen tobacco regulatory systems. A government inquiry ensued despite the FDA’s documentation of their adherence to regulations on receiving foreign grants. The FDA Director General resigned shortly after.17
Tobacco Industry Interference in Politics
Tobacco industry interference in politics has been documented worldwide.18 This influence is particularly strong in the Philippines, which is a tobacco exporter described as having the “strongest tobacco lobby in Asia”.19 Many proponents of the Vape Bill have longstanding ties with the tobacco industry. When the Philippines attempted sin tax reform through progressively higher excise taxes on tobacco in the 2010s, these proponents submitted bills that backed anti-sin tax proposals from the tobacco industry.10–12
In addition, legislative processes within a government system may be vulnerable to strategic moves that further protobacco interests.20 In the Philippines, this was manifested when the Vape Bill passed from the government’s legislative branch to its executive branch. If a Philippine president does not approve or veto a bill 30 days after receiving it, the bill automatically becomes a national law.21 The bicameral legislature approved the Vape Bill in January 2022. However, the bill was transmitted 5 months later to the President, who was a strong antitobacco advocate, just 5 days before the end of his term. The bill then became law without approval nor veto from his successor, who originates from a tobacco-growing province.
Moving Forward
In the Philippines, we will continue to advocate for youth protection and tobacco control. The constitutionality of the Vape Bill may be challenged because the shift in regulatory authority appears contrary to a constitutional mandate to “maintain an effective food and drug regulatory system”.22 In addition, it is crucial that the public, especially young people, are informed about the risks and harms of ENDS through school educational initiatives and mass media campaigns. Lastly, we recommend initiating a national surveillance system for ENDS and tobacco use in youth to identify tobacco use behaviors and associated factors. Research should be conducted on the impact of the Vape Bill on ENDS and tobacco use in our youth.
What Are the Next Steps for Tobacco Control Advocates Around the World?
Implementing Effective Public Policy
Effective public policy is crucial to protect children from ENDS. Countries formulating ENDS legislation can incorporate a variety of evidence-based tobacco control measures. This includes comprehensive smoking bans, flavor bans, advertising and promotion bans, online sales bans, an increased minimum age for the sale of tobacco products (eg, Tobacco 21), graphic health warning labels, sponsorship restrictions, and increased excise taxes on tobacco. Funding can be derived from the excise taxes and funneled toward tobacco-related programs for prevention, treatment, education, and research. Surveillance and longitudinal monitoring of youth ENDS use also merits priority.
Future challenges to the authority of health-related agencies over ENDS are likely. Inspiration can be taken from the US FDA’s Deeming Rule in 201623 to ensure that health advocates have control over ENDS. We believe that public health and safety will be best protected by ENDS regulation that is developed via a public health lens, not a commercial one.
Addressing Tobacco Industry Interference
Nations must recognize and act on the various forms of tobacco industry interference in policy and public health. Article 5.3 of the World Health Organization Framework Convention on Tobacco Control and its supporting resources provide a framework of action for governments to address tobacco industry influence and achieve transparency and accountability in the government.24–26 Nongovernment organizations and academia also play an essential role. They can monitor the tobacco industry’s activity and compliance with regulations and identify and report any interference to the media and government. It should be recognized that tobacco control will require multisectoral support and collaboration with key players including policymakers, community leaders and members, health professionals, and educators.
The Role of Pediatricians
Finally, we highlight the role of pediatricians in tobacco control and prevention. Smoking is a pediatric disease and pediatricians are vital in protecting children from tobacco exposure and use. Pediatric health visits provide a crucial opportunity for screening and intervention. Pediatricians can screen for ENDS and tobacco use and exposure in patients and family members and provide prevention counseling and anticipatory guidance. Those who use ENDS and/or tobacco may be offered motivational interviewing, cessation counseling, enrollment in quit lines, and referrals to treatment extenders for further support.
There is a critical gap in ENDS research on prevention and intervention strategies for youth.27 Pediatricians can engage in collaborative research with youth and allied health professionals to develop these. Together, they can identify effective messaging which resonates with young people and determine sustainable and lasting interventions for vaping cessation.
Beyond this, pediatricians can participate in political activism by educating policymakers about the harms of ENDS, advocating for proyouth measures in legislation, and mobilizing peers and colleagues to do the same. They can also reach out to their local pediatric society chapter or tobacco control group to learn about and participate in ongoing efforts.
Conclusion
Much remains to be done to protect children from tobacco. We can implement effective public policy, address tobacco industry interference, conduct research on ENDS prevention and cessation in youth, and align and coordinate global efforts toward tobacco control. International linkages in the pediatric and tobacco control communities must be strengthened so that information and resources can be shared and built toward the goal of ending the tobacco epidemic.
Dr Puyat conceptualized and designed the piece, conducted the literature review, drafted the initial manuscript, and revised the manuscript; Dr Robredo, Dr Tiam-Lee, and Dr Eala conceptualized and designed the piece, conducted the literature review, drafted the initial manuscript, and reviewed the manuscript; Dr Domingo and Dr Hemedez-Gonzalez conceptualized and designed the piece, conducted the literature review, and reviewed the manuscript; Dr Dans conceptualized and designed the piece, conducted the literature review, and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
CONFLICT OF INTEREST DISLCOSURES: The authors have indicated they have no potential conflicts of interest relevant to this article to disclose.
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