With over 267 million tobacco users in India, the country needs a solution to its tobacco problem. Rushing into unilateral approaches to this multifaceted problem by banning e-cigarettes needs careful thought and reflection. By suggesting an outright ban on the less harmful alternative option, Electronic Nicotine Delivery Systems (ENDS), the Indian Council of Medical Research (ICMR) could be missing the point.
Studies by credible International institutions show that e-cigarettes are less harmful than tobacco cigarettes. In 2014 and 2015, Public Health England (PHE) published a report stating that e-cigarettes are unlikely to have more than five percent of the risk of tobacco cigarettes. The PHE again updated their report in 2018 and reported no changes from the original conclusion. According to a recently published survey by the United Kingdom’s National Health Service (NHS) conducted across 200 schools in England, e-cigarettes are not causing youth to smoke and youth smoking rates are declining at an encouraging rate. The survey further reveals that vaping remains largely concentrated amongst those who are already smokers.
The cohort studies on which ICMR based its recommendations show a high probability of bias from sources such as combining ‘subjects’ with or without a quit motivation. On the contrary, an analysis of a large US population survey indicated that the substantial increase in e-cigarettes use between 2010 and 2015 was significantly associated with an increase in smoking cessation. Experts have suggested that this is linked to quitting smoking being the main reason for e-cigarettes use, for the majority of current and former smokers.
Many countries have acknowledged the immense potential of e-cigarettes in reducing tobacco harm, given that while smoking cessation is ideal, it is not always realistic. In February 2018, the American Cancer Society (ACS) published its Position Statement on Electronic Cigarettes. It said, “Some smokers, despite firm clinician advice, will not attempt to quit smoking cigarettes and will not use FDA approved cessation medications. These individuals should be encouraged to switch to the least harmful form of tobacco product possible; switching to the exclusive use of e-cigarettes is preferred over harmful combustible products. These individuals should be regularly advised to completely quit using all tobacco products.”
The United States’ Food and Drug Administration (USFDA) and the UK’s Medicines and Healthcare Products Regulators Agency (MHRA) even recommend long-term use of nicotine in the form of alternatives, if needed, to maintain smoking cessation, prevent relapse, or even reduce smoking. The ICMR’s stand is at variance with this. It says e-cigarettes cause sustained nicotine dependence among people who have managed to quit smoking. It is a known fact that most of the adverse effects of cigarette smoking are due to the toxic and carcinogenic by-products of combustion. In contrast, nicotine is a low-risk chemical. In such a situation, condemning e-cigarettes for fear of sustained nicotine use in people who’ve managed to wean off smoking will be akin to throwing the baby out with the bathwater.
The available evidence on e-cigarette aerosol chemistry indicates that any risk of harm, if present, is extremely low, and orders of magnitude lower compared with tobacco smoke. In addition, because of the lack of side-stream emissions, e-cigarettes aerosol emissions contribute only minimally to environmental exposure and are very unlikely to cause any substantial health concern. Also, unlike tobacco smoke which increases carbonyl levels in room air, exhaled e-cigarette vapor contains minimal levels of carbonyls. Carcinogenic risk of e-cigarettes, as compared to traditional cigarettes, is extremely low.
It is difficult to understand why the ICMR’s white paper recommends a complete ban on e-cigarettes for the ‘greater interest of protecting public health’, while the traditional cigarettes continue to sell in the market. India is a member of the WHO Framework Convention on Tobacco Control (FCTC) and is bound by MPOWER policy recommendations to lower the tobacco demand in the country and to achieve this, ENDS seems like a practical solution under the harm-reduction policy. The ICMR’s white paper says “long term health effects of e-cigarettes are unclear”. The experts have failed to assess that the impact could equally be negligible or even beneficial (example- slowing neurogenerative diseases). The extraordinary risk of smoking is well known and the potential for e-cigarettes to decrease that risk is highly plausible based on the ten years of experience that is already exists.
On the other hand, not only is prohibition a poor solution to public health in India, but it may lead to illegal trade, counterfeits and poor-quality substitutes. In a recent interview, former FDA Commissioner, Dr. Scott Gottlieb had held the use of counterfeit, illegal e-liquids responsible for nearly 150 cases of lung disease in the US. He stated that while the regulated e-cigarette manufacturers adhere to Good Manufacturing Practices (GMP) and are duly inspected by the FDA to ensure that they do not contain harmful chemicals, counterfeits of suspect quality that are coming in from countries like China under no regulatory supervision and are dangerous.
Earlier this month, over 60 leading specialists in nicotine science, policy, and practice, from 20 countries, including myself, wrote to the Director-General of the ICMR Dr. Balram Bhargava, urging him to reconsider their decision on the ban recommendation. In a country like India, where tobacco use kills about one million people every year, and where tobacco products are readily available at local shops, the safer alternative options could help strengthen existing tobacco control measures to address the problem at large.