India's Policy Stance: Balancing Health and Choice for a Smoke-free Future

India recently celebrated World Health Day on 7 April. India has one of the highest burdens of disease, with a significant proportion of deaths attributable to non-communicable diseases (NCDs), such as heart disease, stroke, cancer, and diabetes. NCDs are largely preventable through healthy lifestyle choices, such as eating a healthy diet, getting regular exercise, and not smoking, or at the least adopting responsible smoking choices.

Nirupama Soundararajan and Arindam Goswami, in this article put light on balancing health and choices . The views expressed are personal. Nirupama and Arindam are both Partners at Policy Consensus Centre and are authors of the report “Re-evaluating the Ban on Alternatives to Conventional Smoking Tobacco Products”.

India has been strongly advocating for a tobacco free country and over the years has put in place various policies that have been focussed on better public health and tobacco harm reduction. However India cannot become completely smoker free overnight. In the meanwhile, India should also focus on providing responsible alternatives for those who already consume traditional smoking tobacco products.

Internationally, many countries have suggested the use of e-cigarettes as a more responsible smoking choice. The UK NHS actively advocates for its use as a smoking cessation tool. India however chose to ban e-cigarettes in 2019 through the Prohibition of Electronic Cigarettes (production, manufacture, import, export, transport, sale, distributions, storage and advertisement) Act. The government believed that the ban would help advance tobacco control efforts of the government for better public health and contribute to the overall reduction in tobacco consumption and its associated health burden.

While India has made phenomenal strides in reducing the instance of smoked tobacco from 34.6% to 28.6% of the population due to strict tobacco control measures, India still has almost 100 million smokers as per the Global Adult Tobacco Survey, 2016-17 (GATS-2) for whom providing a more responsible choice is necessary. This survey was also the first to collect some data on the knowledge and usage of e-cigarettes.

The survey recorded that only 3.03% were aware of e-cigarettes of which a negligible 0.66% were users. Unsurprisingly the younger population were more aware of e-cigarettes; 3.95% of those between 15-24 years were aware of which only a negligible 0.54% had used e-cigarettes. Corresponding figures for the 25-44 years age group were 3.39% in terms of awareness and 0.71% in terms of usage of e-cigarettes. The usage was also more of an urban phenomenon.

When e-cigarettes were banned in India, literature on their health impact was still being studied. An ICMR paper that recommended the ban relied heavily on the USFDA stance that e-cigarettes were more harmful than traditional smoked tobacco products. The ICMR report also stated that India’s ban is justified because WHO urged its member countries since they believed that e-cigarettes did not lead to smoking cessation and that they could hinder established nicotine-replacement therapy solutions that are already present.

However, much has changed since the ban. A recent report by Policy Consensus Centre, titled “Re-evaluating the Ban on Alternatives to Conventional Smoking Tobacco Products,” discusses new literature, new technological developments, and new regulatory frameworks that have evolved globally and recommends for the ban to be re-examined.

First, new literature has emerged to suggest that e-cigarettes are infact a safer alternative to conventional smoked tobacco products. This is because, e-cigarettes do not burn tobacco. Carcinogenic substances that pose significant health risks are emitted when conventional tobacco products are burned. In the case of e-cigarettes, the delivery of nicotine is either through heating (not burning) the tobacco, or the nicotine is delivered directly in a controlled aerosolized manner. Studies have suggested that the short term and medium term impact of using e-cigarettes has led to smoking cessation.

Second, with technologies evolving, these alternative products’ manufacturing features can be regulated to ensure that they are tamper proof, release only regulated quantities of nicotine, and even regulate their fundamental manufacturing design. This can address any concern over the abuse of these products for anything apart from what it is intended for, specifically, as a means to use psychotropic substances.

Third, the prices of these products acts as a natural deterrent against youth usage. Typically, prices at INR 5000 and above, they are far more expensive than an average packet of conventional smoked tobacco products. Furthermore, the government can regulate to ensure that no flavouring agents are used and that single use products continue to remain banned to protect you from experimenting. Furthermore, the GATS-2 survey already suggested, even at a time when the ban was not in place, only a negligible percentage of youth population actually used these products.

Fourth, there are now plenty of international instances of countries that have chosen to regulate e-cigarettes rather than ban them. As many as 75 countries have created a new classification for e-cigarettes and have created separate regulations for them, 62 countries regulate e-cigarettes similar to tobacco products. Very few countries have actually banned them.

It is time for India to re-evaluate the ban on alternatives to conventional smoked tobacco products. New studies have been led to USFDA and WHO amending their initial stance regulating these products rather than banning them. India too would be better off regulating e-cigarettes rather than banning them. Regulation would allow the government to control the sale and marketing of e-cigarettes much like any other tobacco product in the country, and it would ensure that the million people in India who continue to smoke, atleast have access to more responsible and potentially less harmful alternatives.