Tobacco control is a major public health challenge in India; cigarette smoking is the top cause of avoidable deaths, responsible for a million deaths each year. Whilst some of the government’s control measures have been successful, the impact has been minimal, with efforts resulting in a decline of smoking rates of only 6% from 2010 to 2017. In some states, such as Tamil Nadu, consumption is on the rise.
We need to make a clear distinction between the consequences of smoking and the consumption of nicotine; nicotine is addictive, but there is no evidence it is carcinogenic. The harm from cigarette smoking comes from the tar produced by the burning of tobacco, which releases thousands of chemicals, of which about 80 are carcinogenic. British psychiatrist Mike Russell once said that people “smoke for the nicotine, but die from the tar.” Therefore, there needs to be a clear decoupling of the two substances, and a realistic alternative available to support harm-reduction efforts.
If tobacco is the enemy, then we must consider ways of separating nicotine and tobacco, and find a delivery mechanism that provides a credible alternative to conventional smoking. There is growing appreciation that electronic nicotine-delivery systems (ENDS), or e-cigarettes, provide a credible and satisfying alternative; they pose fewer health risks and crucially eliminate combustion from the process.
A study by Public Health England showed that “vaping is a fraction of the risk of smoking, at least 95% less harmful, and of negligible risk to bystanders,” whilst research conducted at the Department of Biochemistry, North-Eastern Hill University in Shillong, found that e-cigarettes reduce the risk of cancer by 90-92% compared to conventional cigarettes. Further still, a report by the Royal College of Physicians stated that “smokers can be reassured and encouraged to use (ENDS), and the public can be reassured that (they) are much safer than smoking.” Clinicians should, therefore, encourage smokers to consider e-cigarettes as a realistic aid to smoking cessation and should share the wealth of credible research on the category to confirm the benefits.
Countries that have legalised, regulated ENDS—the UK and Canada—are witnessing a historical reduction in the prevalence of smoking. A major study by Public Health England has found that e-cigarettes have become the most popular aid for smokers to quit; smoking rates and tobacco-related deaths are now at their lowest levels, and continue to decrease. There is also no conclusive evidence that ENDS are a gateway to smoking.
The way ahead for India
The Union health ministry recently issued an advisory to all states to encourage that ENDS are not sold, manufactured, distributed, traded, imported and advertised in any manner. Nine states have already implemented this. What is important to understand here is that there are various credible studies that indicate ENDS are safer than cigarettes. Considering banning seems like a knee-jerk reaction and might not be a long-term solution. Smokers should have the option/opportunity to move to safer means.
In my view, banning a product that aims to support the elimination of tobacco smoking to better the lives of adult smokers in India serves no purpose. The government should instead look at regulating the e-cigarette market, rather than an outright ban, particularly since tobacco smoking remains legal and products are readily available. Regulations could include strict measures that keep e-cigarettes out of the hands of minors and creating awareness about the relative risks of nicotine. A ban on e-cigarettes is likely to encourage the illicit trade of black-market products, which could result in trading of harmful components and deprive public health officials from legitimately assessing the potential public health benefits of e-cigarettes. It may also send a wrong message that conventional cigarettes are safer than e-cigarettes.
-The author is President, Heart Care Foundation of India