E-cigarettes and heat-not-burn tobacco products, currently banned in Lebanon, will soon be made available by the country’s Tobacco Regulatory Authority, locally known as Regie. Lebanese health authorities did not have their say on the issue.

They are everywhere: on restaurant terraces, bars, offices and even on our television screens, for example, they were often seen in the recent Ramadan dramas. Electronic cigarettes, marketed by hundreds of young brands like Juul or Vaporesso, have been on the Lebanese market for nearly four years. Recently, these nicotine liquid vaporizers were joined by another innovation from tobacco giants, the devices known as "heat-not-burn" tobacco products. Philip Morris International's (PMI) Iqos, British American Tobacco's (BAT) Glo and Japan Tobacco International's (JTI) Ploom have become increasingly popular in Lebanon, which has the world's third highest number of smokers per capita.

Even though the use of e-cigarettes is tolerated, these next-generation alternatives to traditional cigarettes, which are promoted as being less harmful by the companies marketing them, are prohibited on Lebanese territory, at least officially. Consumers have to get them from abroad, or from the duty free section at Beirut Airport to skirt the prohibition, or buy them on the black market.

These devices are usually expensive. "Vaporizers cost between $40 and $140 depending on the type of device, and between $20 and $30 for refills," says a clothing salesman in Tarik el-Jdidé, who keeps a stock of e-cigarettes in the back of his shop.

"The demand is high, but we cannot always meet it; the delivery of the goods is a complex operation," explains the trader who sells a dozen devices a day, not to mention refills. For heat-not-burn tobacco, and in particular Iqos, prices are even higher: around $200 for the latest version of the device on the Internet and $35 for a cartridge of heat-not-burn tobacco sticks at the airport.

The first attempt to regulate these products started in 2013. The Ministry of Health had received an application to allow the import and sale of electronic cigarettes as a nicotine substitute to fight tobacco addiction. On the advice of a technical committee, electronic cigarettes were seen not as a form of medication, but a product equivalent to normal cigarettes, the request was denied.

Two years later, in 2015, it was the Ministry of Finance that got the upper hand. As the supervisory body over the Tobacco Regulatory Authority - which has a monopoly over the distribution of tobacco products in Lebanon - it regulates the import of e-cigarettes, and includes under this name both the flavored liquid heating devices and heated tobacco products. Ironically, the two decisions were signed by the same person, Ali Hassan Khalil, successively Minister of Health and then Finance. "The two departments have diverging interests," says the Tobacco Regulatory Authority concisely.

However, three years later, e-cigarettes are still not being sold on the market legally. There is one main obstacle remaining, according to the Tobacco Regulatory Authority: determining the level of taxation on these products.

This decision is not trivial. "You have to choose between maintaining 113% excise and duty rates as for conventional cigarettes, or lower taxes that would give a boost to these devices, if they are considered less harmful to people’s health," explains Georges Hobeika, Secretary General of the Authority.

A way to quit, or a new addiction?

Producers naturally argue for a favorable tax framework, especially multinationals that have no interest in their new products being treated as tobacco, even if they do contain tobacco. Iqos generates higher margins than conventional cigarettes in countries with a favorable tax regimen like Japan, said Philip Morris International's Director of Operations, Jacek Olczak, in a Bloomberg report in April.

For his part, the Lebanese Minister of Health does not differentiate between e-cigarettes, which may contain more or less nicotine, a poisonous and addictive chemical, and heat-not-burn tobacco products. "I consider them just as dangerous as the conventional cigarette, with the same effects on health," says Minister Jamil Jabak, "With this view, I align myself with the opinion of the World Health Organization. "

The WHO is indeed very firm with regards to heat-not-burn tobacco products, and says they require "additional independent studies", but is more moderate regarding electronic cigarettes. "The limited testing has revealed wide variations in the nature of the toxicity of contents and emissions," the WHO said in a 2014 report. It admitted that certain types of e-cigarettes may be less toxic to smokers when used in moderation by an adult smoker and as a total substitute for smoking. The health hazards remain a controversial topic throughout the medical community. 

A helpless Ministry of Health

In Lebanon, even though tobacco is a risk factor for two of the three most common cancers - bladder and lung - and these diseases cost the taxpayer more than $200 million each year, health authorities have not had their say. "We have no opinion on this matter, it is not the prerogative of the Ministry of Health," says Minister of Health Jamil Jabak.

The General Directorate of Customs has the final say on the matter and its decision could be made in the coming weeks, says the regulation authority. Le Commerce du Levant could not reach the Customs for more information. "It is very surprising that this decision belongs to an organization with no medical expertise," says Dr. Ghazi Zaatari, head of the WHO Study Group on Tobacco Product Regulation (TobReg).

The role of the Ministry of Health is limited to the terms regarding the sale of these products. In particular, it will have to decide on the health warning messages that will be displayed on their packaging. "This tobacco product is not risk free and is addictive," is for the moment the written warning displayed on the Heets and Iqos tobacco sticks available at the airport. "Duty free products are subject to different regulations. On the Lebanese market, the messages will be stronger,” promises Jamil Jabak.

Jabak, a doctor himself, also assures that the "vapes" and the heat-not-burn products will be subject to the anti-tobacco law. Into force since 2012, in theory, it regulates the sale, promotion and consumption of tobacco in public spaces. However, the law is only partially enforced today. "It will be implemented," says the Minister.

Lack of supervision

But even if enforced, law 174 does not address all the challenges posed by electronic cigarettes. In particular, it does not address the issue of nicotine levels - the chemical responsible for smoking addiction - in "e-liquid" refills.

The European Union, for example, in a directive applicable to its member states issued in 2016, set a maximum nicotine concentration target of 20 mg / ml of "e-liquid". In the United States, where the limit has not been set, this concentration can reach 50 mg / ml, especially in the case of the brand Juul.

The US Food and Drug Administration (FDA) plans to adopt stricter terms concerning the sale of flavored liquid refills, which have been criticized for their proliferation among young non-smokers. According to a study published in December by the National Institute on Drug Abuse, more than one high school student in three say they tried vaping in 2018, an increase of 10% over one year and ten times higher than for conventional cigarettes. "In the face of a health disaster, the FDA wants to reverse the trend," comments Ghazi Zaatari.

Lebanon, however, does not seem ready to learn from these experiences. "The anti- tobacco committee, under the leadership of the Ministry of Health, of which I am a member, has not even met for four years," says Ghazi Zaatari.

This article was originally published in French.