India's Ban on E-Cigarettes Ignites Debate on Public Health

Electronic cigarettes and reduced harm products have been banned in India for almost three years, while the legal sale of cigarettes, bidi and other tobacco products continues.

There is a serious debate about what this national public health policy means, but officials from the Department of Health are not eager to participate in any discussions.

India is facing a significant issue in the tobacco industry, being the world's second-largest consumer of tobacco after China, with a market worth $30 billion. Tobacco use has reached alarming levels with nearly 267 million adults (age 15 and above) accounting for 29% of all adults in the country being tobacco users. Usage is higher among communities with lower socio-economic status and education levels in rural areas. Male (43%) tobacco usage is significantly higher than that of females (14%). The prevalence of tobacco use varies widely among different states, ranging from almost 10% in Goa to nearly 70% in Tripura.

The most common forms of tobacco use in India include smokeless tobacco, with popular products such as khaini, gutkha, betel nut with tobacco, and zarda. Smoking is also prevalent with bidi, cigarette, and hookah being popular forms of use.

However, despite the availability of reduced harm alternatives for smokers, these products have not been effectively incorporated into tobacco control policies to supplement traditional measures, such as taxation and graphic warnings on cigarette packaging.

The Ministry of Health and Welfare has released a proposal to ban the manufacture, distribution, and sales of electronic cigarettes, rather than regulating the category to potentially reduce smoking rates and improve public health outcomes.

Experts claim that this is a worrisome development and requires careful reconsideration.

Let's take a realistic look at the studies circulating in the market. They suggest that electronic nicotine delivery systems (ENDS), such as e-cigarettes and vaping devices, only represent a small fraction of smoking risks because they crucially eliminate combustion in the process.

Several globally recognized public health organizations, such as Public Health England, the Royal College of Physicians, the American Cancer Society, and the National Academies of Sciences, Medicine, and Engineering, have acknowledged that electronic cigarettes pose a lower potential harm. Additionally, these organizations are supported by the Indian Heart Care Foundation, which has prepared a consensus statement on the hazards of tobacco, signed by leading doctors in India.

A series of studies conducted in India indicate that traditional cigarettes contain significantly higher levels of toxic chemicals such as Class 1 carcinogens, respiratory toxins, and carcinogenic metal ions compared to ENDS vapor. For example, cadmium, a heavy metal belonging to Class 1 carcinogens, respiratory toxins, and reproductive and developmental toxins, was found to be approximately 1,400 times more prominent in cigarette smoke compared to e-cigarette vapor. Similarly, lead and chromium, which are classified as 2b possible carcinogens, were found to be 12 and 13 times more common in cigarette smoke compared to e-cigarette vapor, respectively. Other carcinogenic substances such as polycyclic aromatic hydrocarbons, which are abundant in tobacco cigarette smoke, are nonexistent in e-cigarettes.

However, officials from the Ministry of Health have not relaxed their efforts.

Experts say that the myths spread by vested interests are influencing the perception of electronic cigarettes. A scientific debate on reducing the harms of tobacco must be based on stringent evidence. Furthermore, there is a widespread failure to distinguish between electronic cigarettes and combustible tobacco products, leading to similar restrictions being imposed on both. Additionally, many people try to classify electronic cigarettes as tobacco products due to the extraction of nicotine from tobacco.

Health department officials must realize that this is entirely unreasonable and lacks scientific basis.

The foundation for reducing the harms of tobacco lies in eliminating combustion, a process that generates nearly all the toxins inhaled by smokers and leads to a high risk of disease and death. Electronic cigarettes do not burn and do not contain tobacco. Existing scientific evidence suggests that the harms of e-cigarettes are much lower than those of traditional smoking. In fact, they fully fit the definition of harm reduction in the tobacco field.

Researchers often misinterpret data and manipulate it to suit their narrative. Even though it has never been proven that Electronic Nicotine Delivery Systems (ENDS) lead to subsequent smoking, its contribution to the overall smoking prevalence is minimal. However, ENDS has become increasingly appealing to smokers, making it the perfect tool to distract them from traditional tobacco cigarettes.

For years, officials from the Ministry of Health have been aware that the use of Electronic Nicotine Delivery Systems (ENDS) is allegedly increasing among young people, particularly those who are trying e-cigarettes. So, what has happened? Smoking rates have decreased significantly. For instance, in the United States, during the period of ENDS popularity (2011-2017), the smoking rate among young people declined by over 50%.

ENDS provides millions of smokers who are unable or unwilling to quit with a less harmful yet satisfying alternative. Banning them is a violation of basic human rights by the health department.

Consumers must have the right to choose, and the government must allow them to do so because consumers will make appropriate decisions based on their own judgement.

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