Tobacco cessation is a noble goal without question. But will it ever be achieved in the face of government ownership of tobacco companies, increasing tobacco farming, misguided laws and foreign lobby groups pushing narrow agendas?
It is also worth questioning how change in the tobacco-use landscape can become a reality in India when there is a ban on Electronic Nicotine Delivery Systems (ENDS) which are now the most popular means to quit smoking worldwide, even as most of the other cessation methods advocated by the government, such as counselling and nicotine gums, have either failed due to poor rollout or are out of the reach of the common man?
A case, therefore, needs to be made that in a country with such a large tobacco-using population, consuming a wide variety of products, and inadequate quit support, maintaining complete cessation as the only goal is unrealistic and should give way to an expanded and more pragmatic mission of reducing tobacco-related death and diseases through substitution and harm reduction measures.
In this context, a recent paper by Chelsea Boyd on tobacco and harm reduction in India makes an interesting case for reversing the ban on ENDS in India.
She delves into our tobacco ecosystem with a nuanced take on the health burden of tobacco (4% of our population are cigarette smokers, 7.7% smoke bidis and 21.4% are smokeless tobacco users), the breakdown of the tobacco marketplace (ITC sells 80% of cigarettes, with ~30% of it being owned by the government), the various pieces of tobacco legislation, and the pitfalls and shortcomings therein.
Boyd then makes a strong argument for the importance and need of tobacco harm reduction. "Given the large proportion of the population that uses tobacco, India is a prime location for applying tobacco harm reduction strategies… by preventing access to alternative nicotine delivery systems, the Indian government has eliminated the chance of effective tobacco harm reduction in a country that needs to use all available means to decrease its smoking and tobacco use rates," she notes, concluding,
"Paramount to advancing harm reduction in India is reversing the ban on electronic nicotine delivery systems and reduced-risk oral products."
The paper also makes interesting observations about the unintended but de facto ban on snus, a significantly harm reduced smokeless tobacco product from Sweden, which has been misclassified as a "food product" and falls afoul of the Drug and Cosmetics Act 1940 and Food Safety and Standards Act 2006 which were intended to ban tobacco from toothpaste and tooth powders, and nicotine as a food additive. Snus can be a successful low-risk substitution for India's 200 million smokeless tobacco users.
Boyd's paper is restrained when it tries to address the glaring contradictions in India's tobacco control programme. For instance, bidis are smoked by a larger portion of the population and are deemed far more dangerous, and yet unlike cigarettes, they are not mandated to carry pictorial warnings, as a recent notification was withdrawn after the protest by a powerful political group.
This indicates India's tobacco policies are not driven by public health interests, but by political motivations.
If we are truly serious about cessation efforts, we would ask our government why it only taxes cigarette smokers, who deposit the majority of the annual Rs 53,000-crore tobacco tax in government coffers, while bidi smokers and smokeless tobacco users comprising a majority of the tobacco-using population and using the deadliest products are hardly troubled - isn't this part of the FCTC demand side interventions?
Further, state ownership of tobacco products is a clear conflict of interest vis-à-vis its obligations and responsibilities under WHO's Framework Convention on Tobacco Control (FCTC) treaty, Article 5.3 of which specifically bars such involvement.
Making the situation worse is the government's staunch refusal to learn from the experience of other countries on limited, and often negative, outcomes of bans and prohibition.
The ban on ENDS and snus, therefore, is not only ineffective but is causing more harm and is symptomatic of the failure to understand and address the continuum of risk, as seen in lighter regulation of more deadly bidi and chewing tobacco versus cigarettes.
The idea that ENDS or vaping is as dangerous as combustible tobacco is laughable in face of overwhelming scientific evidence on their significant risk reduction.
Further, the prevalent notion that nicotine is carcinogenic has to be discarded for the unscientific propaganda that it is.
If India chooses to reverse the ENDS ban, it will be in a stronger position where it can set the ground rules, regulations and safety standards and require the industry to toe the line.
With prohibition, it has only driven the trade underground and beyond its oversight. The very class of citizens - the underage - it aimed to protect with a ban are now the most vulnerable to unregulated access from the black market.
Allowing snus, or better yet nicotine pouches that are also orally consumed but do not contain tobacco will serve to address the large proportion of smokeless tobacco users.
Boyd's suggestion that these less harmful products be taxed in a risk-proportionate manner will further help in transitioning tobacco users to lower down on the spectrum of harm.
Any legislation can have multiple unintended effects. The danger lies in not course-correcting when such defects become evident. That is why we have amendments.
(Dr. Kiran Melkote is a director of Association for Harm Reduction Education & Research (AHRER), a body of medical professionals focused on risk-reduction interventions in public health.)
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