Another year records over 13 lakh tobacco deaths in India alone because regular combustible cigarettes and tobacco remain widely available to all ages

WWhile other countries reconsider their tobacco control options and embrace tobacco harm reduction, with some even reversing previous bans on nicotine vaping, we in India seem obsessed with the “implementation” of an ill-conceived ban on ENDS/E-cigarettes. People have even filed PILs against e-cigarettes and become instant celebrities.

In all this noise, no one appears to care that regular combustible cigarettes and tobacco remain widely available to all ages - with the last GYTS (Global Youth Tobacco Survey – 4) even showing 8.5% of current underage tobacco users with an average age of initiation at 9-11 years (Total population of 0-16-year-olds: ~ 38-40 crores or 25% of our population) – there are multiple tobacco sellers in plain sight of schools yet we hardly bat an eyelid. Why is this not worrying anyone enough to file PILs against this? Why no one is calling for the “implementation” of the cigarette and tobacco laws banning sales to minors?

Yet, if we are fixated on e-cigarettes or rather nicotine vapes (or I’ll start calling nicotine gum cigarette gum), it’s time we take a long hard look at the infamous ICMR white paper on ENDS released 4 years ago that led to the ban on the manufacture, transport, sale etc. of nicotine vapes. The paper called for a complete ban on vaping but the law does allow personal use.

This paper was roundly criticized at the time by renowned global experts as well as by senior doctors at the All India Institute of Medical Sciences (AIIMS), New Delhi.

The claim of harm reduction was incorrectly assessed by the ICMR paper. The contrast should have been between risks posed by nicotine vapes versus risks posed by cigarettes and bidis. Instead, the contrast was between uncertain long-term health effects versus widespread nicotine addiction in youth. So what harm exactly does “nicotine addiction” cause? Especially if the nicotine is separate from tobacco.

Looking at the various proven carcinogens and toxic chemicals in tobacco and the clear absence of these in nicotine vapes, there is no magical process by which vaping becomes nearly as dangerous as smoking. The relative risks have been estimated as 95% to 99% safer than cigarettes and even if these figures are overstated, the fact remains that nicotine vapes are far, far safer than cigarettes or bidis. There is no combustion in nicotine vapes (apart from poorly designed lab studies where vaping coils are overheated and burned to failure and the smoke is inhaled by poor trapped rats). In the real world, a vaper getting a “burnt taste” from a dried coil would immediately stop and get a new coil or cartridge. Every single time.

Nicotine vapes were also implicated in the EVALI outbreak where illegal THC cut with Vitamin E acetate was found to be the culprit. Despite the wide availability of nicotine vapes, there has not been a corresponding rise in EVALI. Papers with an unsound methodology that claimed vaping caused heart disease have also been retracted.

The ICMR paper also called into question “tobacco cessation claims” of nicotine vapes saying they were unproven. On the contrary, nicotine vapes are now the most popular means to quit smoking worldwide. A recent Cochrane review in Nov 2022 (78 studies, 40 RCTs, total of 22052 subjects) showed “high-certainty evidence that ECs with nicotine increase quit rates compared to NRT”. The UK government has even launched the “swap to stop” programme where 1 million smokers will receive free nicotine vapes to reach a smoke-free society by 2030. A statement by 15 past presidents of SRNT (Society for Research on Nicotine and Tobacco) calls for considering the use of nicotine vaping as a means to double the quit rate. The preponderance of evidence globally is in favour of nicotine vaping as preferable to smoking.

A prominent concern also raised by the ICMR paper was about vaping being a “gateway” into tobacco use and ending up in a “nicotine addiction” even after cessation of smoking or as some folks have put it: exchanging one addiction for another. We need to consider two things here. First, nicotine is not carcinogenic and is not associated with the detrimental effects of tobacco. There are no studies that have established any detrimental effects of long-term nicotine replacements.

Second, the “gateway” theory has been comprehensively debunked in the real world. The same youth who smoke tend to also vape. It’s not vaping that has suddenly led to young people picking up a smoking habit.

The ban on nicotine vaping has not served the cause of tobacco control. It has instead boosted cigarette sales and led to the current situation where youth awareness of vaping has increased to nearly 25%. A situation where tobacco control people think nicotine vapes are more dangerous than cigarettes or bidis and have largely ignored the latter.

(The author is the director of the Association of Harm Reduction Education and Research)