A customer smokes at a vape store in Manila on November 20, 2019. Dante Diosina Jr,  AFP/File 

MANILA (UPDATE) — The Philippines has documented its first death due to e-cigarette or vape-associated lung injury (EVALI), health advocates announced during a forum coinciding World No Tobacco Day on Friday.

The case was published in April in the Respirology Case Reports journal of the Asian Pacific Society of Respirology by Dr. Margarita Isabel Fernandez and other doctors of the Philippine General Hospital (PGH) in Manila.

During the forum, Dr. Rizalina Gonzalez of the Philippine Pediatric Society explained that the patient was a 22-year-old male who had no prior health issues, but died of heart attack in 2023, following severe lung injury linked to vaping.

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Gonzalez said the patient did not smoke cigarettes before, but was enticed by different types of vapes, which he used daily for the past two years until he died.

"Healthy, sporty... walang bisyo, non-smoker. Pumunta sa PGH kasi sumisikip ang dibdib tapos may ubo. ‘Pag kita sa lungs niya, puti - so iyong tinatawag nating white-out lung. So in layman's term, pwede nating sabihing parang nabura iyong clear lungs niya kasi binara. Iyong mga vape chemicals, naka-induce ng pamamaga at tsaka iyong tinatawag na inflammation. Ngayon, iyong ding vape na iyong ang naging cause para maging barado ang mga ugat sa kanyang heart, kaya nagkaroon ng parang nag-heart attack, iyong tinatawag nating mycardial infarction," she told reporters at the sidelines of the forum.

(He was healthy, sporty, had no vices, and a non-smoker. He went to PGH because of chest tightness and cough. When his lungs were examined, they were white-out or obstructed. The vape chemicals induced swelling or inflammation. Now, the same vape was the cause of the blockage in his heart vessels, leading to a heart attack or myocardial infarction.)

"So double whammy: barado ang lungs, burado ang lungs, barado ang puso... Namatay siya in spite of all the efforts na ginawa ng mga doktor sa PGH. Ito ay ang unang documented case.”

(He had blocked lungs and blocked heart. He died in spite of all the efforts made by the doctors at PGH. This is the first documented case.)

Gonzalez believes the patient is a "victim of misinformation".

"Hindi naman kasi sasabihin mong sila iyong may kagagawan (You couldn't say that they were at fault), but it's actually the deception, the tobacco industry interference. What have they done with the laws? Yeah, we have lost but we still have to improve this loss.”

"We have to protect our children, the young from the tobacco industry because this vaping, e-cigarettes, electronic smoking devices are very, very harmful. You are still developing, growing, and you'd be productive, and you should not be having that rest in peace.”

The said victim is one of the six cases of EVALI recorded in the Philippines to date, according to the Department of Health (DOH).

Other cases include a 16-year-old dual smoker from Central Visayas and a 22-year-old from Alabang, who used to smoke cigarettes then shifted to vaping.

Gonzalez said the patient did not smoke cigarettes before, but was enticed by different types of vapes, which he used daily for the past two years until he died.

"Healthy, sporty... walang bisyo, non-smoker. Pumunta sa PGH kasi sumisikip ang dibdib tapos may ubo. ‘Pag kita sa lungs niya, puti - so iyong tinatawag nating white-out lung. So in layman's term, pwede nating sabihing parang nabura iyong clear lungs niya kasi binara. Iyong mga vape chemicals, naka-induce ng pamamaga at tsaka iyong tinatawag na inflammation. Ngayon, iyong ding vape na iyong ang naging cause para maging barado ang mga ugat sa kanyang heart, kaya nagkaroon ng parang nag-heart attack, iyong tinatawag nating mycardial infarction," she told reporters at the sidelines of the forum.

(He was healthy, sporty, had no vices, and a non-smoker. He went to PGH because of chest tightness and cough. When his lungs were examined, they were white-out or obstructed. The vape chemicals induced swelling or inflammation. Now, the same vape was the cause of the blockage in his heart vessels, leading to a heart attack or myocardial infarction.)

"So double whammy: barado ang lungs, burado ang lungs, barado ang puso... Namatay siya in spite of all the efforts na ginawa ng mga doktor sa PGH. Ito ay ang unang documented case.”

(He had blocked lungs and blocked heart. He died in spite of all the efforts made by the doctors at PGH. This is the first documented case.)

Gonzalez believes the patient is a "victim of misinformation".

"Hindi naman kasi sasabihin mong sila iyong may kagagawan (You couldn't say that they were at fault), but it's actually the deception, the tobacco industry interference. What have they done with the laws? Yeah, we have lost but we still have to improve this loss.”

"We have to protect our children, the young from the tobacco industry because this vaping, e-cigarettes, electronic smoking devices are very, very harmful. You are still developing, growing, and you'd be productive, and you should not be having that rest in peace.”

The said victim is one of the six cases of EVALI recorded in the Philippines to date, according to the Department of Health (DOH).

Other cases include a 16-year-old dual smoker from Central Visayas and a 22-year-old from Alabang, who used to smoke cigarettes then shifted to vaping.

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 WHAT IS EVALI?

Gonzalez explained that EVALI pertains to a severe case of lung disease due to the use of e-cigarettes or vapes.

For the condition to be declared EVALI, conditions have to be met: the person should have been vaping for at least 90 days and no comorbidities, including diabetes, hypertension, cardiovascular disease, metabolic conditions, and bacterial, viral, or fungal infection.

The Philippines has yet to have the full capacity to test all cases as this requires a respiratory panel, which is tedious and expensive.

Still, this doesn't mean that doctors cannot act early.

"Pagka meron ka nang nakitang bata na nagsisigarilyo, nagve-vape ng more than three months, screen mo na iyan for possible lung disease... Kasi parang end-disease na iyong EVALI. Tapos kung nabuhay ka sa EVALI... iyong chronic obstructive pulmonary disease... para iyan iyong... fiber. Parang ganoon ang itsura noong lungs na iyon. Kaya nga nagiging oxygen-dependent, hindi ka na makatakbo, laging hinihingal. Eh iyong oxygen kailangan iyon ng puso... Damay damay lang ang nangyayari," Gonzalez said.

(If you see a young person smoking or vaping for more than three months, screen them for possible lung disease because EVALI is an end-stage disease. And if you survive EVALI, you might develop chronic obstructive pulmonary disease, where the lungs become fibrotic. That’s why you become oxygen-dependent – can’t run, always short of breath. And the heart needs oxygen too so everything gets affected.)

The doctor said vapes appear to have "smaller but stronger" nicotine content.

For Dr. Maricar Limpin of the Action on Smoking & Health Philippines (ASH), smoking and vaping are "equally harmful," and "we can expect the same harmful effects," including heart and lung diseases, cancer – which may eventually lead to death.

Based on the Global Youth Tobacco Survey (GYTS) more youth aged 13 to 15 have experienced using e-cigarette at one point in their lives – from 11.7% in 2015 to 24.6% in 2019.

Speaking to the youth, DOH Spokesperson Assistant Secretary Albert Domingo warned them that inhaling nicotine causes blood vessels to constrict or narrow, which limits the amount of blood that flows to one's organs, including the heart.

"Mga kabataan, nakakasira ng puso ang vape. Paano na iyan; kinalimutan ka na nga niya, nag-vape ka pa? Sirang-sira na ang puso mo. Iyong puso niyo, okay lang masaktan kung pag-ibig pero huwag niyong saktan na vape ang gamit," he said.

(Young people, vaping can damage your heart. What now? Not only did they leave you, but you also vaped. Now your heart is completely broken. It's okay for your heart to be hurt by love, but don't hurt it with vaping.)

That's why Gio Hontiveros, who is 20 years old and has been vaping for the past seven years, plans to quit the vice soon.

"Iniiwasan ko, kunwari pag tapos kumain... pinipigilan ko sarili ko para 'di na magsigarilyo," he told ABS-CBN News.

(I'm avoiding it. After eating, I restrain myself from smoking.)

Hontiveros admitted that he didn't know about vapes until he saw them on social media advertisements. He was eventually enticed and has been spending PhP 400 a week to buy the disposable type.

"‘Pag nagtatrabaho, tanggal stress... Hinahanap na po ng katawan ko lalo na ‘pag sobrang pagod, vape, nare-relax," he said.

(I vape when working to relieve my stress. My body craves it especially when I'm exhausted; vaping helps me relax.)

REFORMS

To improve data collection, Domingo said they are looking into the inclusion of "clinically suspected" cases in official data for EVALI cases.

The official said the Health department is also supportive of a ban on all types of e-cigarettes.

"That's what we want, but we have to follow the law... Kami po ay sumusunod sa batas. Naipasa po ang Republic Act 11900. Pero kahit po kami ay sumusunod, hindi ho kami sang-ayon... Gagawin namin ang tungkulin namin, pero ‘pag tinanong kami kung gusto namin ng ban, ang sasabihin pa rin ng DOH ay gusto namin ng ban," Domingo shared.

(That's what we want, but we have to follow the law; we adhere to Republic Act 11900. But even though we comply, we do not agree. If asked, the DOH will still say we want a ban.)

Domingo and Limpin also called for the amendment of the Graphic Health Warnings Law to standardize the packaging for cigarettes and e-cigarettes: use only plain-colored packaging so as not to entice smokers, while photo/s of health warnings should occupy "80 percent" of the packaging.

Despite the opposition of the DOH and health experts, the controversial "Vape Bill" or the Vaporized Nicotine and Non-Nicotine Products Regulation Act, lapsed into law in 2022.

Under the law, the age restriction for such products was reduced from 21 years old to 18 years old, and permitted flavorings, advertising, and sponsorship strategies.

The regulation of the products was also transferred from the FDA to the DTI.

Meantime, Sen. Pia Cayetano said since there is already a law on e-cigarettes, these are considered legal to date – but there must be "very strict regulations".

"Iyong Vape Law ngayon, sobrang watered down iyon kasi nga ‘yung access - from 21 years [old], naging 18 years old po. Iyong flavors pwede na, and then iyong jurisdiction... So nag-Blue Ribbon [Committee] hearing na ako to see what the government agencies that are tasked to regulate itong very harmful products are doing kasi laganap siya. Can you imagine a generation of children now addicted to products that are very harmful na nakakamatay pa?" she told reporters.

(The current Vape Law is severely watered down because the age access has been lowered from 21 to18 years old. Flavors are allowed now. In terms of jurisdiction, we conducted a hearing at the Blue Ribbon Committee to see what the government agencies tasked with regulating these very harmful products are doing because it's rampant. Can you imagine a generation of children now addicted to products that are very harmful and can even cause death?)

"We need to keep talking about this. We need to make our senators, congressmen policy makers... to make evidence-based decisions. Our decisions today will affect the children today, tomorrow, the future. So kung ang mga basehan lang natin is may mga kaibigan tayo sa tobacco industry, sabi nila mas safe daw iyon - that's not the way to do our work properly (If our only basis is our friends from the tobacco industry saying certain products are safer - that's not the way to do our work properly). And the research will show you that these are harmful," she added.

Cayetano also asked the private sector to look at the health aspect and follow the law properly.

She stressed that there is also no need to promote "sin products," including cigarettes and vapes, so as to get more taxes.

"The beneficiaries of the Sin Tax Law are primarily all the hospitals, the public hospitals... But does that mean, sige promote na lang natin iyong mga paggamit ng sin products, promote pa natin para gumanda ospital? No, it doesn't work that way. Simply, pagkabumili ka ng product na iyon at least may makukuha (tax) para kung kailangan gamutin, eh 'di meron. But the logic is not to encourage the use of these harmful products," she Cayetano explained.

(The beneficiaries of the Sin Tax Law are primarily all the hospitals, the public hospitals. But does that mean we should just promote the use of sin products to improve hospitals? No, it doesn't work that way. Simply put, when you buy those products, at least there's tax revenue generated that can be used for treatments if needed. But the logic is not to encourage the use of these harmful products.)

For its part, the Philippine College of Chest Physicians said it is working with the Department of Education to include in the curriculum the harmful effects of e-cigarettes.

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