In the absence of proper research and laws around vapes, it is almost impossible to arrive at a conclusive decision with respect to their use.
Electronic cigarettes and other Electronic Nicotine Delivery Systems (ENDS) such as vapes, e-hookahs and e-cigars are now banned in India, but for many, these devices served as a “safer” alternative to cigarette smoking — the numero uno cause of preventable deaths in the world. The Union Cabinet’s decision comes at a time when governments globally are taking a stringent stance on vaping (a fashionable term for using vapes), ever since a string of mysterious vape-related illnesses gripped parts of the US, leaving public health experts and doctors baffled. The safety element of these devices has increasingly been refuted by studies conducted globally. For instance, an August study published in Science Daily Journal, conducted by researchers at the Perelman School of Medicine in the University of Pennsylvania, reveals that using an e-cigarette can harm blood vessels even when the vapour produced is entirely nicotine-free. Another white paper published by the Indian Council of Medical Research in May points out that a typical e-cigarette cartridge contains “as much nicotine as a pack of 20 regular cigarettes and can act as a potential source for nicotine addiction”.
Despite studies claiming otherwise, many adult smokers have admitted to benefiting greatly from vape use, as it served as an able and ‘healthier’ alternative to cigarette smoking, primarily due to the way a vape is designed. An e-cigarette or vape is a handheld battery-powered device that releases nicotine present in cartridges fit inside in a solvent form (vape juices for instance), which becomes vapour upon inhaling. Over 460 different brands and more than 7,700 flavours of vape juices were being marketed in India before the ban came into being. These devices were available in various swanky shapes and sizes that resemble a traditional cigarette and even daily-use products like pens and USB drives. Vapes are labelled safe because they do not burn tobacco and, unlike their traditional counterparts, they are devoid of carcinogenic chemicals and tar that cigarette smoking entails.
The results of a clinical trial published earlier this year in the New England Journal of Medicine (NEJM) note that e-cigarettes are twice as effective for smoking cessation as the nicotine patch, which is currently the standard treatment to help people quit the addiction. Over 2.5 million former smokers in the US have successfully kicked the butt by switching completely to vaping. In the light of this, the government-induced blanket ban on production, manufacture, import, export, transport, sale, distribution, storage and advertisement of e-cigarettes received a mixed response from the public, with many terming it a part of big tobacco lobbying. Vape users took to various social media platforms, arguing that a ban should be imposed on traditional cigarettes and tobacco products first, as they are known to cause over 7 million deaths across the globe annually. The move faced backlash particularly because shares of traditional tobacco firms listed on the Bombay Stock Exchange – ITC, VST Industries, Golden Tobacco and Godfrey Phillips India – rallied instantly following the announcement. A closer look at the shareholding pattern of these companies reveals that the move is bound to benefit the government financially, too, as it holds a 28.64% stake in ITC along with other state-owned companies as of June end.
Besides, knowledge about the manufacturing of vapes, their composition and substances used in making vape juices is shrouded in ambiguity in the absence of well-specified and laid down regulations. Historically, even the USFDA has never regulated e-cigarettes, in the sense of tapping the manufacturers of vapes and juices, and conducting checks on the ingredients used and the processes employed. Rajiv Goyal, the owner of Mascot Studio, a retail store in Delhi’s Greater Kailash M Block market that used to sell vapes, had said weeks before the ban that he was fine with going through any number of checks if the government decides to regulate the e-cigarette market. “Because no one has done any research, and there is some cloud of mystery around vapes, the government wants to ban its sales outright. We are okay with as many checks as possible. Numerous food, alcohol and tobacco shops have closed down due to the use of cheap and illicit raw materials. Why can’t the government conduct similar checks in shops and stores selling vapes? Whoever is selling illegal, cheap products will be caught,” Goyal said.
Since purchasing vape juices is an expensive and cumbersome process, a lot of people across the globe have also taken to creating juices on their own using information available online. They believe that it’s safer than the variants available in the market. However, preparing juices at home using cheaper raw materials can be far more dangerous sans the knowledge about ingredients used in flavours. Vapes, commonly used to derive nicotine, can also be used to deliver psychotropic substances like tetrahydrocannabinol (THC), and butane hash oils, besides cannabidiol (CBD), an essential component of medical marijuana, much like cigarettes and hookahs. Since cannabis and hashish trade in most countries takes place illicitly, it is likely that synthetic and counterfeit raw materials are involved. Authorities investigating the cases of illnesses and deaths in the US have vouched for this.
Even though the exact cause of deaths and illnesses originating from vaping is yet to be ascertained, a couple of worrisome facets have come to the fore. “An e-cigarette aerosol can expose users to substances such as ultrafine particles, heavy metals, volatile organic compounds, and other harmful ingredients known to have adverse health effects,” a September New England Journal of Medicine study reveals. Moreover, vape juices have come under scientists’ radar as they detected the presence of new chemicals in the solvents that aren’t listed on the ingredients’ label. In several cases, even the label is missing. These flavours are usually made by mixing nicotine and flavours in a solvent, mostly propylene glycol, vegetable glycerine, or a mixture of the two. In the past three months, a spate of mysterious vape-related lung illnesses has rocked hospitals in parts of the US. What looked like lung infections of sorts were later termed severe pulmonary ailments, fuelled by the alleged use of vapes and e-cigarettes. Such is the case that lungs of plenty of adolescent patients were found to be in much worse shape than those of a septuagenarian. The practice of vaping is now being touted as an epidemic, with the US Centers for Disease Control and Prevention reporting 530 cases of illnesses and eight deaths.
Irrespective of whether vapes are deemed safe or not, doctors and medical practitioners have never advocated its use, and recommend de-addiction courses and medication, instead. “We as chest-physicians never approve of any kind of e-cigarettes because it is definitely not a way to get rid of smoking. The only way of getting rid of the habit is to quit smoking altogether, and management of withdrawal symptoms by symptomatic treatment. Vapes have their own issues like usage of formaldehyde, which means even if there is no addictive nicotine, there are enough chemicals that will keep one hooked to it,” says Samir Garge, consultant, respiratory medicine, at Jaslok Hospital and Research Centre in Mumbai.
Besides flavour and heat-originated harm, vapes have been proven to fuel nicotine addiction, especially among teenagers. According to a September 2019 report published in the NEJM, the prevalence of vaping increased from 11.7% to 20.8% among US high school students in the 2017–2018 period. In contrast, only 3.2% of US adults reported e-cigarette use in 2018. This is mostly due to the ease with which a vape can be used.
“There’s a downside, which I have personally felt. When I used to smoke cigarettes, I would look for an appropriate place. Like most of us typically do not smoke in our homes, we can’t even smoke in offices… but that’s not the case with a vape,” says 26-year-old Prateek Prashar, a Mumbai-based senior sales manager at a legal SaaS start-up. “You can take a drag anywhere, it doesn’t leave any ash, smell or anything. Smoke detectors do not detect the vapours released from vapes. If self-control is not too strong, it definitely can lead to a graver nicotine addiction, as I noticed in my case,” Prashar adds. He had made the switch to vaping last year after being a social smoker for several years but relapsed soon in a bid to curb his nicotine dependence. “Vapes can definitely not be marketed as safe products. Anything that involves addictive substances, nicotine in this case, should not be deemed safe,” says Rajat Johar (name changed), a 25-year-old Gurugram-based consultant, who had been using vapes for over a year now.
Safer than cigarettes?
Advocates and supporters of vaping never endorse the practice as ‘safe’ either, but maintain that it is much better than regular smoking and tobacco use. For instance, Association of Vapers India, a not-for-profit organisation formally set up in 2017, started regarding vaping as safe on their portal after a community of smoker-turned-vapers saw big tobacco companies and state governments lobbying for the removal of e-cigarettes and vapes. “No one’s actually saying that vaping is harmless. All we’re saying is that it’s much less harmful than smoking cigarettes. It is known since long that people smoke for the nicotine, but die from the tar that is essentially the residue cigarette leaves. Tar contains 7,000 chemicals, 80 of which are carcinogenic,” explains Samrat Chowdhery, founder-director of the association. “In a moral society, we would want people to not have addictive habits. In a practical world, however, we would strive to provide people with a safer alternative to those habits.
The approach that we’ve taken so far is that of stigmatising and penalising. We’ve levied charges on smoking in certain public spaces and are putting smokers in designated cubicles. What we at the association are asking for is, why not take a better approach and make these 1.1 billion smokers in the world a part of society while providing a means that would not kill them,” Chowdhery adds. Prior to the ban, vape had come to the rescue of 33-year-old media professional Priyanka Mittal (name changed), when all other ways of quitting the deadly habit of smoking had failed. She had seen her friend transition to vaping rather smoothly and did her “fair bit of research” before purchasing a Juul (a swanky vape pen that resembles a pen drive and is manufactured by the US-based Juul Labs) in a bid to quit smoking after nearly a decade of use. “I had started feeling sick of smoking cigarettes… I had a smoker’s cough, it would get worse during a viral infection. ‘
Besides, I had been wanting to quit since really long, but fell victim to the withdrawal symptoms every time,” she recounts. “Around new year’s time, I resolved to quit smoking and transitioned to vaping. The device and pods are expensive, but I was soon able to resist the urge to smoke at all. Initially, I would use the device around eight-nine times a day, and now, almost nine months later, I don’t even feel like I need nicotine… I am quite hopeful of giving up the vape too,” she says. Even though vapes aren’t touted or marketed as safe products, public health advocates argue in favour of their use, solely with the purpose of keeping cigarette smoking at bay. “From a public health perspective, it is ludicrous to ban e-cigarettes and allow the real cigarettes to continue to be sold. This is definitely an overreaction. E-cigarettes are helping many smokers to quit,” says Michael Siegel, a doctor and professor at the Boston University School of Public Health. “I think the ideal approach is to promote e-cigarettes for adult smokers to help them quit while running campaigns to discourage youth vaping at the same time. In addition, we need to regulate e-cigarettes by setting safety standards for these products, but not by banning them. I think we should restrict the sale of ALL nicotine products —both e-cigarettes and tobacco cigarettes — to adult-only facilities that would only sell these products,” he adds.
Manufacturers of vapes and e-cigarettes had urged the government to look at the harm that cigarette smoking entails and then make an informed decision on vapes, prior to the ban imposition. “What is the government doing about the millions of deaths that happen every year due to smoking? If public health is of actual importance, the government should first ban the traditional cigarette in every form and shape,” Delhi-based Lokesh Jain, director of India operations at UK-based Litejoy International that had been selling e-cigarettes and vapes since 2012, says. Mittal, who switched to vaping after years of being dependent on cigarettes for her daily nicotine fix, says a blanket ban would be “unfair” to people who wish to quit. “Why does the government want to take the easy way out by banning these devices altogether? They should set an age limit for the sale and purchase of these products instead. Have proper laws in place, regulate the sales, purchase, manufacture; close down shops and companies that are selling to the younger generation,” she says.
The ban debate
Last week, the government took strict action against vapes and e-cigarettes, in the light of growing doubts around their safety. The Promulgation of the Prohibition of Electronic Cigarettes (production, manufacture, import, export, transport, sale, distribution, storage and advertisement) Ordinance, 2019, provides for imprisonment of up to one year or fines up to Rs 1 lakh or both for the first offence and imprisonment of up to three years and a fine of up to Rs 5 lakh for a subsequent offence. Storing e-cigarettes is now punishable in India, entailing imprisonment up to six months or a fine up to Rs 50,000 or both. Those with existing stocks of e-cigarettes on the date of commencement of the ordinance will have to suo motu declare and deposit these stocks with the nearest police station.
In the US, Michigan, Massachusetts, New York and San Francisco have banned flavoured e-cigarettes. The counterfeit and black markets of vapes thrived even before the ban was imposed. Ahead of the Ordinance, retailers had argued that a ban would instead open greater avenues for the black market to function. “An iPhone’s counterfeit could be made, the vape is still a tiny device.
As of the question of imposing a ban, if it does come into effect, the prices and sales of these devices and their juices would only increase, as it has happened with all the other illegal products,” said Awadhesh Kumar (name changed), who used to sell vapes in his stall in Saket, a residential colony in south Delhi. Besides known names like Juul, Godfrey Phillips India, brands like Skol, Naked 101, Myle, Vaporesso, Smok belong to higher-price brackets. Local brands coexist and are available for as little as a few hundred bucks. The price range of the vape juices varies between Rs 100 and Rs 1,500, depending on the brand, flavour, nicotine content, etc.
In the absence of proper research and laws around vapes, it is almost impossible to arrive at a conclusive decision with respect to their use. Even as the mysterious illnesses in the US have put vapes under a cloud of suspicion, can the advantages associated with it be overlooked altogether? Public health experts and doctors are divided. “These products are truly saving lives of adult smokers. So far, the vaping-related illnesses appear to mostly be related to the use of marijuana vaping products available in the black market, not e-cigarettes sold in retail stores or online,” says Siegel. Garge contradicts, arguing anything that involves the practice of smoking or vaping should be banned in all forms. “Vapes are the stepping stones that take one to smoke and drug abuse. One killer habit cannot be cut with a lesser evil. It has to be cut from its roots,” he says.