India is one of the worst affected countries from tobacco addiction. With more than 27 crore active tobacco users and around 13.5 lakh annual deaths, the country is in the throes of a tobacco epidemic. The government and non-profit organisations have been striving to control and reduce the prevalence of tobacco use; however, their efforts have met with little to no success. Government reports based on limited public surveys show marginal decline in the problem, however the growing sale volumes and revenues of the tobacco companies contradict the claim.
It is common knowledge that tobacco causes cancer and other health issues such as hypertension, Chronic obstructive pulmonary disease (COPD), bronchiolitis, asthma, ischemic heart disease and atherosclerosis. Despite being aware of this fact, thousands of people especially youth take up tobacco use every year. Experimental phases of life, peer pressure, stress and curiosity are some of the reasons why people use tobacco. Many people who try tobacco once get addicted to it. In a country like India, where tobacco addiction is neither seen as a medical condition nor as a social stigma, most people who want to quit rely solely on their willpower. It is estimated that only five per cent of such people have success. Considering this fact, it is imperative to have a support system to assist tobacco users to achieve their target of quitting.
So far, India has employed tobacco control methods like higher taxes on tobacco products, pictorial warnings, ban on advertising and public smoking and penalties for underage selling. However, the growing number of users and tobacco-related deaths indicate that these methods have been inadequate. Other legislative methods to control tobacco usage like counselling, nicotine replacement therapies and drugs have also had very limited success and the menace of tobacco use is steadily growing. Many of these therapies are expensive, and thus not affordable for most tobacco users in the country.
Several countries worldwide have done excellent work in tobacco control. Apart from well-funded and dedicated tobacco control programmes, the common element in the success of countries like the UK, Sweden and Japan is the availability and popularity of safer and harm-reduced alternatives. India must also embrace harm reduction if it sincerely wants to see reduced tobacco related deaths.
Harm reduction is a well-accepted practice in all walks of life. All of us look for and use harm reduction methods and equipment in our lives on a daily basis. Helmets, seat belts, condoms, sanitisers and masks are used to minimise risk in our daily life. Sugar-free sweeteners reduce our sugar intake. Sunflower and rice bran oil let us consume our favourite dishes with less chance of heart disease. Even for tobacco consumption, the concept of harm reduction is available in the form of nicotine replacement therapies (NRT). However, such therapies are not well received in the public as it is expensive or perceived as medicines.
The need is for affordable and enjoyable safer alternatives which the user might willingly adopt, without any persuasion or prescription. In a country like India where tobacco is consumed in many different forms like bidi, cigarette, gutkha and paan, the government should promote safer alternatives rather than banning it.
There are different types of safer alternatives available for tobacco users, however last year India enforced a regressive ban on all such products. These alternatives to smoking include nicotine patches, nicotine gums, smokeless tobacco such as snus, vaporised nicotine delivery systems such as electronic cigarettes and heated no-burn tobacco devices. Varenicline is a drug which acts on the nicotinic receptors of the brain and helps stop nicotine cravings. Nicotine gums and patches use pure nicotine either added to a gum base which is to be intermittently chewed, or added to an adhesive patch, which is stuck to the skin and delivers nicotine over an extended period. Several studies in Sweden and the United States have found that snus is about 98 per cent safer than smoking or chewing tobacco. The US FDA recently approved snus as a reduced risk tobacco product.
Almost all nicotine replacement therapies and reduced-risk-products remove Tobacco Specific Nitrosamines (TSNAs). TSNAs are the toxic carcinogens in cigarettes and its removal reduces cancer risk significantly. One needs to understand that nicotine by itself is not carcinogenic and should not be demonised.
Electronic cigarettes gained popularity as a safer alternative to smoking when they were introduced roughly 15 years back. An electronic cigarette uses a coil to heat up a liquid which contains vegetable glycerine, propylene glycol and flavouring. It may or may not contain nicotine. Electronic cigarettes or vaping is the closest to smoking psychologically and has been deemed 95 per cent safer than smoking by the NHS of the UK. Vegetable glycerine, propylene glycol and the flavouring used have all been cleared by the FDA as safe for human consumption.
Vaping came into controversy in July 2019, when several lung related problems and deaths occurred in the United States. This condition was designated the term EVALI—E-cigarette or Vaping product user Associated Lung Injury—and it created a major misconception all over the world, leading to unethical bans. The ongoing study by the US CDC has confirmed beyond doubt that EVALI was caused when illicit cannabis oil which was mixed with Vitamin E acetate was being used to vape. Cases of EVALI have been declining steadily since this observation came to light. Other countries which have regulated vaping and other reduced risk products did not see this unfortunate event. This points that reduced risk products must be regulated, and not banned for them to work. Smoking rates across Europe are now controlled thanks to people shifting to reduced risk products.
The government needs to reassess the actual world data on reduced risk products and bring in a change in the policy for safer alternatives to tobacco consumption. Regulation and not ban should be the way forward. The Indian government needs to be progressive in its vision and not just be a blind follower of others. It is imperative to protect the youth from taking up tobacco. In the long run, this is the best way to reduce, or maybe end, tobacco consumption. However, it is equally important to provide viable alternatives to existing users and encourage use of safer alternatives. The government should look at ways to allow RRPs to adults while restricting their access to youth. At the same time, stricter measures are also needed to reduce the access of traditional tobacco products to our youth. Regulating not banning safer alternatives (vaping devices) is the right approach if the government is truly sincere about controlling the tobacco epidemic in the country.
Tobacco control programmes and the banning of e-cigarettes are two legislatives contradictory to each other. The government of India banned the sale of e cigarettes on 18th September 2019, putting at risk the health of ex-smokers, who had transitioned to a safer alternative. Bans give birth to black markets and increase the chances of spurious and illicit trade. Liquor bans in Gujrat and Bihar do not appear to work on the ground. Ban is not and never will be the silver bullet to tobacco control. Tobacco control is much easier said than done. Tobacco control reforms in India have traditionally faced opposition due to three major concerns—industry, employment and tax revenue. Transitioning users from harmful forms of tobacco to Reduced Risk Products (RRPs) can be done while addressing these concerns. RRPs contain either processed tobacco or purified nicotine, so tobacco farmers will not be affected. Workers in the traditional tobacco industry can be re-skilled to produce RRPs. Companies making harmful products can be encouraged to develop and market less harmful ones and the government can still earn taxes.
Jain is a paediatrician and a founding member of Association for Harm Reduction Education and Research (AHRER)
