Is prohibition the answer to public health?
Policies to manage harm caused by tobacco have long been the centrepiece of public health debates across the world.
To reduce the harm caused by cigarettes on smokers and society, Governments in many countries have invested their resources on understanding the science and technology behind novel tobacco and nicotine products that are better alternatives to smoking. Research and innovation in this space over the last decade or so has allowed them to look at tobacco control in more holistic manner – to include existing tobacco control measures (taxation, health warnings etc.) but at the same time allow and regulate products that are better than continued cigarette smoking.
E-cigarettes sometimes called “Electronic Nicotine Delivery Systems” or ENDS and “Heat not Burn Products” (HNBs) also called “Heated Tobacco Products” (HTPs) are some of the better and potentially less harmful alternatives available to traditional cigarettes. The billion smokers worldwide should be given a choice to choose such alternatives.
E-cigarettes are different from Heat not Burn Products. They are a broad category of electronic products which generate an aerosol by heating a liquid that usually contains nicotine. They do not contain tobacco, like “Heat not Burn products” which heat processed tobacco in a controlled manner to produce an aerosol.
In the UK, the use of e-cigarettes (vaping) as an alternative to smoking has been endorsed by the government and medical professionals. It is backed by research from Public Health England (PHE), subsequently endorsed in a report by the Royal College of Physicians (RCP) and together they have concluded that vaping is far less harmful than smoking cigarettes. Studies show that UK endorsing tobacco harm reduction through use of better alternatives has led to a faster decrease in smoking rate from 20 percent in 2011 to 15 percent in 2018, compared to Thailand’s smoking rate decline from 21 percent in 2011 to 19 percent in 2017 which has an existing ban on this category and types of products.
Similarly, evidence of successful “Heat not Burn Products” regulation can be seen in more than 50 countries in the world including USA, UK, Italy, Japan, Portugal, Russia and Switzerland etc. where they are regulated as a consumer tobacco product, differentiated from traditional cigarettes. The use of Heat not Burn or Heated Tobacco Products is also a better alternative for smokers who will not or cannot quit, and using them instead of smoking cigarettes. The country which has witnessed the largest switching of smokers to such products is Japan. The introduction of Heated Tobacco Products, as a harm reduction approach to existing tobacco control measures, reduced cigarette sales in Japan by 30 percent in a span of three to four years. Historically, such a decline in cigarette consumption has not been observed after years of existing tobacco control measures (higher taxation, health warnings etc.).
In the United States, a significant development has been the Food and Drug Administration authorizing the marketing of a product called ‘IQOS’, the tobacco heating system (Heat not Burn or Heated Tobacco Product), as a modified risk tobacco product (MRTP) on July 7, 2020. The FDA authorized the marketing of IQOS in the US with the information that the IQOS system heats tobacco but does not burn it, and scientific studies have shown that switching completely from conventional cigarettes to the IQOS tobacco heating system significantly reduces the body’s exposure to harmful or potentially harmful chemicals.
As recently as May 25, 2021, in the Philippines, a bill regulating the manufacture, sale, and use of less
harmful alternatives to cigarettes — such as vapes and heated tobacco products (HTPs) — cleared the House of Representatives. The Bill regulates the use of alternative products by prohibits sale to minors, establishes rules around packaging and health warnings, prohibits indoor use and features other measures necessary to curb its consumption amongst unintended audiences.
In India, however, which has the world’s second largest smoking population after China and is also the highest in terms of consumption of nicotine products, the Government has resorted to a legislative ban on such products that are better alternatives to continued use of cigarettes. In September 2019, the Indian Government passed the Prohibition of Electronic Cigarettes Act, 2019. We are well aware that bans are an extreme policy decision and leads to incessant sales on the black market. India has in the past witnessed the failure of bans with restrictions on alcohol sale. For example, in Vietnam, banning of alternatives to smoking by the Government led to a more favourable environment for smuggling than effectively curbing the use of cigarettes.
It is time that the Indian Government takes cue from the legislations regulating novel tobacco and nicotine products around the world and uses them as precedents and allows for a more strict and balanced regulation of such products relying on careful study of the existing evidence and data around such products. A case in point would be the New Zealand ministry which undertook a detailed study of available scientific evidence, published reports and global studies and research and after seeking comments from the public gave a detailed report on the impact assessment and possible legal pathways for regulation of e-cigarettes.
Disappointing as it maybe, but bans, instead of a risk proportionate regulatory framework, seems like an eyewash and isn’t a prudent way to tackle the issue at hand. A shift in the policy makers thought process and a comprehensive regulatory policy for better alternatives to existing tobacco products will go a long way in helping people who cannot quit smoking to choose such alternatives and, in the process, will further the Indian Government’s commitment against the menace of tobacco.
