SINGAPORE — Renovation site supervisor Muhammad Dandiar Rosli thought he would be saving $200 a month when he switched from smoking cigarettes to vaping.
Instead, this change led to him being issued a $40,000 medical bill.
Dandiar was 33 years old when he started vaping in June 2020.
"I was trying to quit smoking because I was getting married, and I needed to save money for the wedding. It was during the Covid-19 period and I did not have the cash to buy cigarettes, so I started vaping because it’s a cheaper alternative," said the now 37-year-old.
He had already been smoking for about 12 years at that point.
A month into the vaping habit, he became breathless and was coughing up thick yellow phlegm in the morning.
"I also experienced shortness of breath doing simple activities like walking briskly. It was in July 2020 that, suddenly, I could not breathe properly. I thought I was having a heart attack," he told The Straits Times.
Dandiar went to the emergency department of Changi General Hospital to seek treatment and since it was during the Covid-19 pandemic, he was hospitalised.
"Due to my shortness of breath, they suspected I might have contracted Covid-19, and I was placed in the HD (high dependency) ward for the next six days. As my breathing problems continued, the doctor wanted to use a bronchoscope to look into my lungs. I declined," he said.
Bronchoscopy is a technique used to look at a patient’s air passages, using a flexible tube with a small camera at the end.
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It was a week after he was discharged that he had another episode and according to the oximeter, his oxygen levels fell to 70 per cent.
"I broke out in cold sweat. I was lying down then. I had not been vaping since I was discharged from the hospital. Once again, I thought I was having a heart attack," he said.
This time accompanied by his new wife, he returned to the emergency room at CGH and by coincidence, it was the same doctor on duty who had insisted on the bronchoscopy.
Following this, Dandiar was diagnosed with pulmonary alveolar proteinosis (PAP), a rare disease in which protein and fatty material build up in the air sacs of the lungs, making breathing difficult.
It can lead to death due to respiratory failure or secondary infections.
In PAP, the air sacs lose the ability to clear the build-up in the lungs. Patients feel like they are drowning from this build-up in their lungs, and they run out of breath easily.
Dandiar was immediately taken by ambulance to Singapore General Hospital (SGH) where he underwent whole lung lavage in both lungs with saline solution.
SGH is the only hospital in Singapore that performs the procedure.
Carried out in the operating theatre, and performed one lung at a time while the patient is under anaesthesia, whole lung lavage uses sterile saline to wash away abnormal build-up of protein from the lung.
The patient has a double lumen tube inserted through the mouth and into the windpipe to isolate the left and right lungs from each other.
A large volume of saline, typically 10 to 20 litres, is infused sequentially in one lung while the patient is ventilated through the other, and the saline is drained out through a bronchoscope until the liquid extracted turns from milky to almost clear.
The whole process takes three to four hours, after which the patient is returned to the intensive care unit and the procedure is repeated for the other lung after one to two weeks.
"Some patients may require additional treatment depending on their response. Patients are strongly advised to stop vaping to avoid triggering their immune system," said Associate Professor Sewa Duu Wen, who heads the Department of Respiratory and Critical Care Medicine at SGH.
Dr Sewa admitted that doctors treating respiratory issues are not always aware that their patients have been vaping.
"Vaping does not leave the traditional signs of smoking such as tar staining of the fingers, smoker’s breath, or unpleasant smell on their clothing. Patients may not mention that they are vaping due to possible social stigma in Singapore and fear of legal repercussions if they admit to possession, use or purchase of vapes," he said.
Dr Sewa added that collaborative history from their family members can also be lacking as users often hide their vaping and the devices are designed to look innocuous.
"Some users have the misconception that vaping is safe and do not associate their health symptoms with their vaping habits, so they do not actively bring this up to the doctors, unless asked directly," he said.
This is why cases of patients with respiratory conditions who vape are not tracked systematically at hospitals.
Systematic tracking of vaping is currently challenging but Dr Sewa said patients could be encouraged to disclose their vaping history.
Healthcare providers could be trained to ask about vaping in a non-judgmental way to foster trust, and explain to patients that disclosing their vaping history is for their medical benefit, not for them to face legal consequences.
Patients should also be educated on the health effects of vaping, and existing electronic health data could be enhanced to include vaping.
In a post on TikTok on July 5, 2024, Health Minister Ong Ye Kung said young people continue vaping despite knowing it is harmful.
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He said vapes contain many other chemical substances of which the effects are currently unknown, and that by the time they are established, "the harm is already done".
In the post, Ong said e-cigarettes do not necessarily contain less nicotine.
"It all depends on user behaviour and how much we inhale the stuff. Based on the pods seized by HSA (Health Sciences Authority), we found that the nicotine content of one pod can be as high as that of four packs of cigarettes," he said.
Citing a Health Ministry study, he said the daily intake of nicotine by cigarette smokers is about 10mg to 40mg; while that for vapers is about 6mg to 90mg.
Ong said e-cigarettes are not a substitute for cigarettes but a gateway for non-smokers to become smokers.
He added they are specifically targeted at the young with their fruity flavours, disguising as something friendly.
Vaping has been banned in Singapore since 2018, and the Republic is one of 39 countries worldwide that have banned vapes.
Offenders can be fined up to $2,000 for possession, use and purchase of vapes. Those who import, distribute or sell such products face stiffer penalties, including a higher fine and a possible jail term.
Yet users continue to buy e-vaporisers, or vapes, online or when they go overseas, despite the ban on these products.
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In a joint statement in December 2023, the Health Sciences Authority (HSA) and the Ministry of Health (MOH) said they are stepping up enforcement and education efforts against vaping to prevent it from gaining a foothold in Singapore.
It was only in June that over 350,000 vapes and components worth more than $6 million were seized from distribution networks as the authorities stepped up efforts to clamp down on vaping.
Among these, the Health Sciences Authority (HSA) found 14 vapes suspected to contain tetrahydrocannabinol (THC), a controlled drug that can cause anxiety, disorientation or paranoia.
Two months after Dandiar was discharged from hospital, he started vaping in secret, saying he was addicted to the high it gave him.
"I smoked behind my wife’s back and tried to hide my cough from her," he said.
But his shortness of breath returned in December 2020, and his wife rushed him to the emergency department at SGH.
The doctor suspected that Dandiar had been vaping and the act triggered the cough and breathlessness.
He had to undergo a second round of whole lung lavage.
"That day, looking at the disappointment in my wife’s eyes and having her call me 'stupid', I made up my mind to give up smoking and vaping, which I should have done in the first place," he said.
This was an expensive lesson, as the four procedures cost him $40,000
"It was paid using both our Medisave but still, it was a big wake-up call," he said.
Dandiar has not had a cigarette or vaped for over three years, and said he is willing to tell his story to inform the young that vaping is not as cool or safe as it appears to be.
"I do not want anyone to go through what I have been through as it was not only painful, it also burnt a huge hole in the pocket," he said.
ALSO READ: 'Popcorn lung', cancer: Experts warn of dangers as vaping among youth in Singapore spikes
This article was first published in The Straits Times. Permission required for reproduction.
