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The discussion over tobacco harm reduction in the United States is an emotional demonstration of dogmatic assumptions. It is true that smoking kills, nicotine does not come without risks to the human body, and that youth should do their best to refrain from the use of tobacco and smokefree products like e-cigarettes. However, there are lines of unethical public health practice. At least in the U.S., smokers don’t risk the pains of potentially being killed just for gunning a stick on their lunch break.
Americans overreact to cigarettes, vaping, and the behavioral intentions of nicotine users. This is a very true phenomenon. Internationally, though, overreaction is categorically redefined. Over the past 12 months of my life, I have reviewed the legal codes of over 100 countries to better understand the regulatory environments for tobacco and smokefree products. Understanding the legal status of tobacco products in other countries through a comparative lens is vital for law and policymakers across the world. What is too lenient? What is extreme? At least from an analysis standpoint, the positions from other jurisdictions inform the global status of population-wide tobacco use recovery.
Consider recent policy events in the Republic of the Philippines. International wire services lit up with reports that the national government abruptly endorsed prohibitions on e-cigarette use and police actions against vapers caught in public. This is a vital development, given the context of the country’s current position not only nicotine, but narcotics, cannabis, and those who use such substances.
The Philippines is led by President Rodrigo Duterte. The Philippine public health law has evolved into one of the strictest tobacco control frameworks in all of Asia. From anti-tobacco campaigns and public-use bans, Duterte has received praise for his position against tobacco use, but at an enormous cost. Not just a financial cost, but a societal one.
Setting the scene
Duterte is a controversial figure. Human rights organizations have long monitored Duterte’s drug control legacy. For those of you who are unaware of this man and his positions, he is widely known as one of the deadliest national leaders against drug dealers and users. Human Rights Watch, for instance, has noted that Duterte has condoned the death of over 12,000 civilians, possibly more, since his ascension to the Filipino presidency over the summer of 2016. Other estimates suggest 20,000 deaths.
He’s in the public record calling for the deaths of all drug users in his country, suggesting that he will defend cops and civilians who carry out vigilantism. This context builds on the backward motivations of the Duterte drug control legacy. As it relates to the president’s recent push against the use of e-cigarettes in public.
“I will ban it, the use and the importation,” Duterte said during a press conference at the end of November. “I hope everybody is listening. Please relay this to them. You know why? Because it is toxic,” he added, while reminding the country that he is an ex-smoker.
Since then, the transition of democracy in the Philippines has not been an easy one. Don’t get me wrong; the Philippines is one of the rising powers in the world and offers one of the most promising emerging economies across the entirety of the Indo-Asian-Pacific region. The Filipino economy is expected to surpass several of its fellow ASEAN members and expects to maintain one of the largest economic standards in all of Asia by 2050, according to HSBC. Despite the current and future economic prowess, the Philippines still caters to a societal environment resting on the shoulders of authoritarians. Duterte, to note, was elected with a plurality of the direct electorate.
39 percent of those who voted in the 2016 general election voted in favor of Duterte’s platform, thereby electing the support of an aggressive drug warrior. Before his ascension to the presidency, Duterte was the long-running mayor of the city of Davao, on the southern island of Mindanao. During his tenure as mayor, Duterte claimed to have presided over one of the safest cities in the entire world. According to national police data, Davao actually had the second-highest rate of sexual crimes and one of the highest numbers of index crime across the Philippines. However, it was Duterte’s ability to navigate the domestic and international media to marshal a narrative that his actions as mayor included comprehensive public safety measures.
Homegrown policies, national impact
Davao, still, is considered one of the safest cities in the world. However, there are strict policies that still disproportionately harm at-risk groups like drug users. We should also consider another example: sex workers. Within Davao, the city is considered to be one of the most family-friendly cities in the county, despite having one of the highest rate of child sex workers by all other measurements.
Duterte also oversaw the implementation of comprehensive anti-smoking measures in Davao that criminalized outdoor and indoor public use, confirmed through a series of mayoral executive orders starting in 2002. As a result, overly aggressive penalties were levied on the shoulders of violators. Anti-smoking measures and other aggressive positions on drug users has created a culture of impunity within the city, according to local, national, and international human rights NGOs. An incident in 2015 involved the Davao police forcing a tourist to swallow his own cigarette butt in a bar as punishment for refusing to comply with the public smoking prohibition in place throughout the city. This incident reportedly caused the constitutional Commission on Human Rights to express deep concern for Duterte and his policy legacy.
When he reached the presidency, Duterte modeled a 2017 national anti-smoking measure on the one that he instituted in Davao City. Officially referred to as Executive Order 26, smoking in public is considered a crime punishable by prison time and fines. At the time of the implementation, the executive order allows police authorities to charge offenders with a maximum penalty of four months incarceration and a fine of 1,000 to 5,000 pesos ($100 at the max on this scale), and covers both indoor and outdoor smoking. The order could also carry up a fine of at least 10,000 pesos ($200), and levies a series of more fines specific to businesses. All of these rules apply to e-cigarettes and vapor products, too. That said, Executive Order 26 has won the support of public health organizations across the country. Such support, though, presents a challenging equation. Duterte’s so-called support for public health is, sadly, bloody.
The unfortunate “death squad mentality”
The Philippines is a country that’s overwhelmingly Roman Catholic. Starting roughly in the 16th century, Spanish explorers began a multi-century occupation (yes, an occupation) of the country straddled to the spread of European religion. Throughout its colonial history, the church became a significant power center. I include this remark in this essay because I value the position of one Catholic organization as it relates to the human rights predicament under the Duterte presidency.
The Catholic Church, just like in other countries, is led by a Catholic Bishops’ Conference of the Philippines (CBCP). During the presidential campaign in 2016, bishops and other prominent clergymen called on voters to defeat Duterte by drawing attention to his egregious human rights record. On several occasions, Duterte has alleged that he has killed people with his own gun. One incident prompted the CBCP to condemn Duterte’s actions and remarks as a violation of human rights and that extralegal law enforcement methods are not ever justified.
It’s entities like the Catholic Church that really provides a sobering assessment of what is happening in the country. This is an important highlight for this case because, as mentioned already, the e-cigarette restrictions are based on a standard operating procedure of criminal intent. The United Nations, NGOs, domestic human rights bodies, the U.S. State Department, other highly developed countries in Asia, and Filippino citizens themselves have corroborated accusations that Duterte acts as a violent despotic populist.
Time magazine dubbed Duterte “The Punisher”, highlighting a campaign of extrajudicial killings against drug users, low-level criminals, and homeless children in the streets of Davao. Further, as president and throughout his political career, Duterte has emboldened the acts of vigilante death squads that have killed thousands. Drug users, specifically, are killed execution-style, with bullets to the head. I am not aware of any case that involves a smoker or a vaper; however, we can’t expect much to be different.
Duterte has also created a sentiment among law enforcement officers that inexplicably justify abuses of power. In an effort to further alleviate the mental anguish from the horrific depictions of this piece, I will spare key details. But, the main issue I find with the e-cigarette ban focuses on two key points. First, the obvious criminalization of a harm reduction product offers a series of cases that splinter the act, behavior, and mentality of nicotine use. However, the scariest part is the abuse of power, as I said. A 2018 report from the U.S. State Department suggests that the drug war has allowed law enforcement officers to get away with rape and other sexual crimes against women with other anecdotal cases including violations against children and members of local LGBT communities. Some of you may find it presumptuous to link the over-policing of drug users and dealers to sexual misconduct had by unaccountable government officials. The truth about this matter, however, speaks volumes. Duterte, like his counterpart in the United States, President Donald Trump, has publicly made sexist and homophobic remarks. One of these remarks shockingly involves Duterte saying that “beautiful women” are at fault for being raped.
The national e-cigarette ban, by consequence, was implemented within this context. It’s nothing but atrocious; however, I must also admit that I can’t accurately speak to the public perception of Duterte, the drug war, strict smoking rules, and other prohibitionist policies. Barring these details, the e-cigarette ban also comes at a time of scientific uncertainty related to vaping products and their relative safety to regular cigarettes.
EVALI arrives in the Perla de Oriente
The United States is suffering from a noncommunicable lung injury outbreak, tied to the behavior of vaping contaminated regulated e-liquids or illicitly sourced products that often contain THC, CBD, kratom, other narcotics, and even nicotine in some cases. Data from the federal Centers for Disease Control and Prevention (CDC), in Washington, D.C., indicates that there are over 2,000 cases of the e-cigarette or vaping product use-associated lung injury (EVALI) diagnosis and nearly 50 deaths linked to EVALI.
The Philippine Department of Health (DOH) reported its first EVALI diagnosis in the middle of last month (November). A 16 year-old-girl from Visayas archipelago was hospitalized and held for six days after she reportedly used a vaporizer and was a dual user of vapes and cigarettes. A DOH communique reports that a private-practice pulmonologist diagnosed the girl along the lines of the CDC’s criteria for an EVALI diagnosis.
“All e-cigarette users should seek immediate medical help, and ask their doctors for ways to quit these harmful products. No e-cigarette product should be accessible to young children and adolescents, who are uniquely susceptible to the harms of e-cigarettes and nicotine. I urge non-users not to even try e-cigarettes at all,” stated Health Undersecretary Rolando Enrique Domingo in a statement from Nov. 15.
Duterte, as already reported in this piece, found this to be enough justification to impose the strict policy on vapor products. Since then, the national police have arrested over 250 vapers highly urbanized centers with an unknown number of those detained still currently incarcerated awaiting official arraignment.