India needs regulatory reforms to win the fight against tobacco

An estimated 12% of the world’s cigarette smokers live in India. Every year, India loses nearly 1.35 million people to smoking and spends 1.16% of its GDP in fighting the tobacco menace. India’s tobacco crisis is exceptionally unique with the prevalence of a complex, ‘rainbow’ landscape. Not only smoking, but a large section of population also indulges in chewing tobacco in the form of smokeless tobacco (SLT) such as khaini, zarda, gutkha, etc. For over 270 million tobacco users in India, there has to be a viable alternative that helps them switch from tobacco dependence to harm-reducing choices such as ENDS i.e., Electronic Nicotine Delivery Systems. ENDS work on the principle of delivering nicotine without combustion, which significantly reduces toxic byproducts to levels orders of magnitude lower than smoking. As a potential substitute for tobacco, ENDS products could lead to a global revolution in public health.

However, contrary to the pragmatic approach, the Indian government considers banning all ENDS products as a measure to control the use from rising. By issuing an advisory seeking all member states to ban manufacturing, distribution, and sale of ENDS, the government has sidetracked from an essential arm of tobacco control— tobacco harm reduction (THR).

India’s problem at present is the indiscriminate access to a wide array of tobacco products at a very affordable price. THR policies help prevent or reduce harm by promoting the substitution of combustible tobacco with less hazardous non-combustible sources of nicotine. THR strategies are aimed at smokers who find it difficult to leave tobacco dependence—something India could largely benefit from.

Even as the government toughens its stance on ENDS, which is arguably a very important and viable alternative for smokers, what are the laws on regulating the use of tobacco— the primary cause of concern? When tobacco is legally sold and easily accessible to all age-groups in the country, can we blame an alternative for the growing menace?

India needs a comprehensive regulatory policy under which the registration of all nicotine products is through a transparent and clearly-defined process. Most importantly, any regulation should be evidence-based and risk-proportionate. For instance, the framework should outline methodologies to either review the scientific evidence behind ENDS’ potential benefits or facilitate conducting independent studies on their merits. Much like any other available product, before a complete ban, ENDS must be evaluated for their role in THR policies and an appropriate regulatory framework should be carved in a comprehensive effort to strengthen the tobacco control environment in the country.

A case in point is UAE, which lifted the blanket ban on ENDS after rigorous scientific research. Furthermore, the reports by Public Health England and the American Cancer Society have pointed out the lack of scientific rationale behind the prohibition on ENDS. Newer generation ENDS are an efficient means of meeting nicotine demand by smokers and can thus aid them in transitioning from tobacco to a viable, less harmful option. If the increase in tobacco consumption has to be targeted, it should involve a three-fold strategy— a) formulation of robust regulation, b) sustained awareness campaigns providing balanced, truthful and reliable information and c) promotion of harm reduction alternatives such as ENDS among adult smokers.

Konstantinos E. Farsalinos Research Fellow, Onassis Cardiac Surgery CenterKonstantinos E. Farsalinos, M.D., is a research fellow at the Onassis Cardiac Surgery Center in Athens-Greece, at the Department of Pharmacy, University of Patras-Greece and at the National School of Public Health-Greece. He has been conducting laboratory and clinical research on e-cigarettes as a principal investigator since 2011.