Does India's Ban on Electronic Cigarettes Improve Public Health Outcomes?

The Indian Public Policy Review is a bimonthly, peer-reviewed and open access journal. It covers original articles, book reviews, and commentaries in fields such as economics, political science, public finance, international relations and security, political and defense strategies, public enterprises, and technology policy. The journal's aim is to promote research and advocacy by providing articles on economic, political and strategic affairs. By launching the journal, it is hoped to encourage academic exchange on Indian public policy research. The journal publishes theory and empirical analysis papers related to Indian public policy issues, assisting scholars to timely publish their research findings, helping students understand and grasp the complexities of policy design and implementation, and giving policymakers insights to address the challenges brought by policy adjustments.

On March 31st, 2023, an article titled "Does India's Ban on Electronic Cigarettes Improve Public Health Outcomes?" was published in a journal by former Indian legislator Shonali Thangiah.

Image source: Front page of the paper "Will India's Ban on E-Cigarettes Improve Public Health Outcomes?" published in the April 2022 issue of the Indian Public Policy Review.

The summary of the paper is as follows:

1. Author Profile:

Mr. M. V. Rajeev Gowda, an Indian politician and scholar, is the author of this article. He served as a Member of Parliament in the lower house and national spokesperson for the Indian National Congress party from 2014 to 2020. He currently serves as the Chairperson of the Congress Research Department. At the Indian Institute of Management Bangalore, he was a professor of Economics and Social Sciences, as well as the Chairperson of the Center for Public Policy, and taught multiple courses. Additionally, he served as a Central Director of the Reserve Bank of India. Currently, he is an advisor to Bridge India, a progressive non-profit think tank based in London, which was established in 2018.

Image source: Homepage of the "M. V. Rajeev Gowda" Wikipedia article.

2. Background Overview:

In 2019, India passed the "Prohibition of Electronic Cigarettes Act," which banned a wide range of electronic nicotine delivery systems (ENDS), including e-cigarettes, vaping devices, and heated tobacco products (HNB). The government justified the ban based on certain risks, including their potential impact on health, their appeal to young people, and concerns that ENDS could undermine tobacco control efforts. This article applies a risk analysis framework to examine whether the ban will improve public health outcomes, or if regulation is a more effective alternative policy approach.

Part III: Discussion of Key Findings

The consequences and current state of the electronic cigarette ban.

Since the ban on e-cigarettes was introduced in 2019, there has been a significant rise in illegal online and offline black markets for electronic cigarettes, which goes against the initial intentions of policymakers. Consequently, many people are calling for more clear and scientific laws and regulations based on the harm reduction principle. Policy-making also needs to consider multiple factors, including economic benefits, tourism, crime rates, and adverse events related to public health. Finally, in the 2021 fiscal bill, the federal government accepted the new classification of tobacco and nicotine products developed by the World Customs Organization Committee, which recognizes the differences in taxation purposes between cigarettes, e-cigarettes, and heated non-combustible products. However, this distinction has not yet been applied in the context of the ban on e-cigarettes.

2. Tobacco Risk Management.

Smokeless tobacco is largely favored by specific demographics, including rural residents, those with lower levels of education and income, and marginalized communities. The dangers of smokeless tobacco are compounded by the unregulated product supply on the market.

In 2003, India instituted the comprehensive tobacco control law known as COTPA, which brought together various regulatory aspects under one framework. Another milestone in tobacco control was the National Tobacco Control Program (NTCP), which funds state-level tobacco control plans.

Risk balance serves as a criterion for evaluating policies.

The risk balance model allows the government to protect non-smokers and prevent overall tobacco use, while also protecting tobacco consumers by providing innovative low-risk products. By implementing bans and refusing to consider the possibility of using e-cigarettes as a tool to reduce tobacco-related harm, the government may also be depriving tobacco consumers of safer alternatives and their right to make informed decisions.

According to the FDA's "continuum of risk" theory, protecting high-risk tobacco products such as combustible cigarettes while banning low-risk products like ENDS and HNB could actually backfire and result in more tobacco-related deaths and illnesses. This would go against the government's basic responsibility to improve public health.

The global situation.

As of February 2021, 73 countries allow the sale of ENDS devices with restrictions (such as the UK, Canada, Malaysia, and New Zealand), while 37 countries have completely banned their sale (such as Australia, Singapore, Sri Lanka, and Thailand). Many countries have incorporated harm reduction principles into their tobacco control laws. New Zealand, the Philippines, Japan, Greece, and Switzerland have adopted risk proportionality and differential regulation for nicotine delivery systems and HNBs. Norway and Uruguay have lifted their ban on new tobacco products. The varied experiences and approaches taken by these countries provide an opportunity for research on how India can learn from them to regulate ENDS/HNB based on risk balance.

Lessons to be learned from the United States and the United Kingdom

The UK has taken a harm reduction approach, considering Electronic Nicotine Delivery Systems (ENDS) as a safer alternative to combustible tobacco. Regulation of tobacco and e-cigarettes falls under the Tobacco and Related Products Regulations 2016 (TRPR). Devices that do not contain nicotine are regulated under the General Product Safety Regulations 2005. TRPR aims to implement the European Union Tobacco Products Directive into UK law, discourage non-smokers, especially young people, from taking up smoking, and assist non-smokers in transitioning from smoking to cessation.

In contrast, the United States has adopted an abstinence approach, banning the use of ENDS in some jurisdictions. As the tobacco regulatory agency, the FDA classifies ENDS as ordinary cigarettes and requires ENDS manufacturers to apply for market approval for new and existing ENDS products in the United States. However, this authorization does not equate to FDA approval or official recognition of ENDS as safe products.

4. The implications for India:

The use of electronic cigarettes in India is limited to a specific demographic, consisting mainly of males with at least a Bachelor's degree and an average age of 29. This differs from those who smoke combustible cigarettes. Prior to the ban on e-cigarettes, only 0.02% of the population used them, compared to 10.7% who smoked traditional cigarettes.

Based on this fact, the author provides the following recommendations:

Initially allowed to heat without burning and regulated in accordance with existing tobacco product laws (i.e. COTPA), as they contained real tobacco. This initially limited the availability of e-cigarette products to HNB (rather than general ENDS), while still paving the way for harm reduction.

To further regulate the use of HNB, conditions such as geographic labeling, age restrictions, consumer purchase limits, and reducing harm information can be imposed under the "reasonable use" policy.

(3) Research on scientific evidence, international best practices, and commissioned studies on how to use HNB as a tool for harm reduction and smoking cessation, including statistical models and decision-making frameworks for comparing various interventions and their public health outcomes.

It will be considered a criminal offense to sell HNB (as well as traditional ENDS) directly or through intermediaries, in-person or online, to minors. Severe punishments will be imposed for any violations of this policy.

A strict regulatory framework should be put in place for HNB (and ENDS) products to prevent the health risks posed by unregulated products on the black market. Restrictions and standards for the devices, such as engineering, design, and materials, will ensure health and safety standards and prevent tampering and misuse through illegal additives.

If e-cigarettes were to be allowed under regulation, restrictions could include limiting the volume of e-liquid, the number of puffs, making refilling devices more cumbersome, and enforcing limitations on flavorings, additives, packaging and advertising. These measures would aim to reduce their appeal to young people and non-smokers.

Perform annual surveys on the utilization and trends of HNB and electronic cigarettes to ensure a proactive, adaptable, and evidence-based regulatory response.

Conclusion:

A policy based on abstinence has created a thriving black market in which the quality of products is unregulated, posing greater threats to public health through false and dangerous products. The government has also deprived itself of legitimate tax revenues. Therefore, the risks and opportunity costs of the ban outweigh the perceived benefits. A risk-balancing regulatory approach recognizes that the government can protect public health by constantly evaluating evidence and revising policies to address new risks. By prohibiting ENDS and HNB devices, the government has created a system that cannot readily respond to the unforeseen consequences it has set in motion. Eliminating this harm legislatively is both time and resource-intensive, and the damage to the health of those using illegal devices may even be irreversible.

Therefore, a evidence-based recommendation for India is to regulate heated tobacco products under the Cigarettes and Other Tobacco Products Act as they use tobacco. This can help reduce harm and promote innovation in the products, thus helping users break free from nicotine dependence and improving India's overall public health outcomes.

References:

Will India's Ban on E-Cigarettes Improve Public Health Outcomes?

Further reading:

According to recent scientific experiments, the flavors of nicotine and cannabis electronic cigarette products are the reasons why more teenagers are attracted to trying them out.

2. Science: Using self-control and perseverance to help quit smoking – an intervention strategy based on the theory of American psychologist Duckworth.

[Science] Latest scientific research reveals the connection between nicotine addiction and human identity cognition.

Latest research shows that the SGM (sexual and gender minority) community has a higher tobacco use rate compared to heterosexual individuals.

The latest release from the Macau Health Bureau's Smoking Prevention and Control Office is an exploration of "the current situation of electronic cigarette use among Macau youth and its influencing factors" in the field of science.