Tobacco Control - Here's An Alternative Agenda For India On Harm Reduction

In a recent submission, Lakshmi Ramamurthy, Hon. Trustee, Centre for Public Policy Research shared her thoughts on how tobacco harm can be curbed at a policy level in the country. She pointed out that India, in its act of imposing a ban on e-cigarettes in 2019, failed to make the distinction between the different classes of products. While in the finance bill of 2021, the government acknowledged the distinction between traditional cigarettes, e-cigarettes and HTP for taxation purposes, this distinction has not been applied in the context of the ban on e-cigarettes.

Panama hosted the Conference of the Parties tenth session (COP10) in February. COP10, under the WHO Framework Convention for Tobacco Control (FCTC), holds immense significance for the future of public health. The FCTC addressed three critical aspects of tobacco control — demand reduction, supply reduction, and harm reduction.

The Conference this time focused on forward-looking measures, exploring cutting-edge technology beyond FCTC, laying the groundwork for COP11. The discussions addressed tobacco's environmental impact, spanning from production and use to filter disposal, while emphasising the enforcement of civil and criminal laws against the tobacco industry. The COP10 declaration also reiterated the Parties' commitment to prioritising public health rights.

As an alternative to harm reduction especially to combustible tobacco used in cigarettes with proven public health impact, various countries across the world have embraced electronic cigarettes (e-cigarettes), such as vapes, and other Electronic Nicotine Delivery Systems (ENDS). Research by different countries have concluded that e-cigarettes are less hazardous than combustible cigarettes.

A study conducted by Public Health England indicates that the risk of passive smoking associated with e-cigarettes is very low, as there is no combustible tobacco. Despite existing research and facts on e-cigarettes, the Finance Ministry of India announced a ban on e-cigarettes in 2019, following which manufacturing, import, export, transport, sale, distribution, storage, and advertising related to e-cigarettes are prohibited. 

This prohibition instituted a comprehensive ban on e-cigarettes, encompassing all forms of Electronic Nicotine Delivery Systems (ENDS), heated tobacco products (HTP), e-Hookahs, and similar devices. Although often grouped together as a single product class, these items constitute a diverse array with potentially significant disparities in toxicant production and nicotine delivery mechanisms.

However, the Indian Government, in its Act failed to make the distinction between these distinct classes of products. While in the finance bill of 2021, the government acknowledged the distinction between traditional cigarettes, e-cigarettes and HTP for taxation purposes, this distinction has not been applied in the context of the ban on e-cigarettes.

The decision to ban e-cigarettes, HTP, and similar products without a thorough examination of the scientific evidence may warrant reconsideration. The establishment of an effective regulatory framework can only be achieved when clear distinctions are made and informed by the scientific evidence regarding these products.

Despite two decades of global tobacco policy control measures, tobacco-related harm continues to inflict premature deaths and remains a leading cause of life-threatening diseases. India, a key member of FCTC, grapples with the challenge of having the world's second-largest number of smokers, approximately 100 million (GATS 2017). ICMR in its Cancer Registry Programme found that tobacco-related cancers accounted for nearly half (48.7%) of the country’s cancer burden in 2021.

India, which has predominantly concentrated on supply and demand reduction, has made notable progress in implementing measures like taxation, content regulation, and awareness campaigns. However, the outcomes of tobacco control have been only moderately successful. India will now have to prioritise scientific and fact-based solutions. A focus on harm reduction strategies that offer safer alternatives can play a pivotal role in reducing tobacco-related diseases and deaths among its vast population.

In India, tobacco consumption poses a grave and costly public health challenge. Approximately 5.3% of India’s healthcare expenditure is allocated to treating tobacco-related diseases, resulting in an annual cost of ?13,500 crore, and in 2023, tobacco-related healthcare expenditure accounted for 1.04% of the GDP. 

The widespread use, particularly in the form of smoking beedi and chewing tobacco, has raised significant concerns for public health in India. Over one million adults in India lose their lives annually due to tobacco use, representing 9.5% of the total mortality rate, making tobacco a leading preventable cause of death in the country. Despite the health risk, the quit rates in India, especially among men, remain low at just 20%. Efforts to combat the tobacco epidemic in India have primarily focused on raising awareness about the health risks of tobacco.

However, despite a high level of awareness, there is limited progress in reducing tobacco use or increasing cessation rates. Addressing these challenges necessitates strategies such as improving access to cessation support, addressing psychological barriers, and countering the influence of the tobacco industry to achieve a meaningful reduction in tobacco use.  

India’s current framework for tobacco control has yet to fully introduce harm reduction strategies, which involve exploring safer alternatives to traditional cigarettes. Countries like the United States, United Kingdom, New Zealand, Sweden, Japan, and Canada have embraced the concept of safer alternatives within their global tobacco control policies.

Harm reduction policies aim to assist smokers in quitting and, for those who do not, encourages them to make less harmful choices to improve public health. In the year 2022, Annual Population Survey of UK reported lowest smoking rates since 2011 with only 12.9% of adult population smoking cigarettes. The latest headlines for Tobacco Duty statistics say that total tobacco receipts for the financial year, 2022-23 were 3% lower than the previous year. Interestingly, 5.2% of the survey respondents stated that they were current users of an e-cigarette, an increase from 4.9% in 2021. 

For India, the key focus should be on scientific harm reduction strategies and further explore cutting edge technology with policymakers across the world. Rather than implementing a blanket ban, a risk-based approach, regulating products based on toxicants, should be considered. By integrating better and safer alternatives and prioritising the reduction of smoking prevalence, India can take steps toward achieving its goal of diminishing the burden of tobacco-related diseases and deaths.