Reproduced from: http://www.businessworld.in/article/The-Indian-Imperative-For-A-Safer-Alternative-To-Smoking/18-05-2019-170453/, published May 18, 2019

by R. N. Sharan

The imperative for including technological innovations such as ANDS and tobacco harm minimization as a supplementary tools to our existing arsenal of tobacco control measures should be, in my considered opinion, the collective priority of the public health communities and governments across the globe to adequately and effectively address the scourge of tobacco and its adverse effects

Tobacco smoking is one of the biggest public health threats to the world today. Ironically, it is a totally avoidable habit, affecting both the users and the bystanders. India is home to an estimated 12% of the world’s cigarette smokers, where approximately 25000 people die every week on account of the habit. In India, patterns of tobacco use are highly complex with multitudes of forms of tobacco and additives. We, therefore, need varied solutions to overcome the unique ‘rainbow’ usage pattern and the tobacco menace in India.

Tobacco is estimated to be the primary cause of 40% of all cancers in India. The reason why people smoke or chew tobacco is to get ‘nicotine’, an addictive chemical. Unfortunately, while nicotine is not a carcinogenic chemical entity per se, there are other carcinogens and toxicants present in tobacco which find their way into the user’s body causing the morbidity and eventual mortality. 

In spite the vigorous enforcement of conventional tobacco control measures under the umbrella of the WHO-FCTC approved approach (taxation, pictorial warnings, advertisement controls, packaging, and varied restrictions, among others) in India, the outcome of tobacco control has been modest at best. 

A comparison of the second global adult tobacco survey (GATS 2), conducted in 2016-17, with the GATS 1 estimates from 2009-10, showed, among others, (a) an absolute reduction in number of tobacco users in India by 6 percentage points (8.1 million), (b) reduction in the prevalence of tobacco smoking in young (15-24 years) population from 18.4% to 12.4%, and (c) increase in the age of initiation by ~  year – from 17.9 years to 18.9 years. While, at face value, these numbers are encouraging, the data needs to be viewed in the back-drop of existing tobacco burden in India. The data from Global Burden of Disease study for India, published over 1 year back, shows that the 6th [ischemic heart disease (IHD)] and 8th [chronic obstructive pulmonary disease (COPD)] disease burdens in India during 1990s have moved up to the positions 1 and 2, respectively, in 2017. Both IHD and COPD have strong causal correlations to tobacco use.

In order to effectively control the existing morbidity and mortality of tobacco in the population, the ideal course would be not to use tobacco in any form. Those who are already dependent on nicotine and smoke tobacco or chew smoke-less tobacco (SLT) to meet their need, require counselling, information and hand-holding for tobacco cessation with the help of available means, which include nicotine replacement therapy (NRT) such as, nicotine patches, gums and inhalers approved by WHO. However, the global patterns of tobacco-dependence and tobacco cessation clearly show that a significantly large population has failed to achieve total or even partial tobacco cessation with the help of such aids. Therefore, to strengthen the ongoing efforts of tobacco control and to accelerate the rate of decline in tobacco use, additional avenues of tobacco harm minimization (THM) need to be considered seriously to supplement the existing NRTs. 

Thanks to developing technology, multiple types of alternative nicotine delivery systems’ (ANDS) are available today. These ANDS can be effective options for those addicted to tobacco as a supplementary tool to help them reduce their dependence on tobacco products to get nicotine, and, eventually, quit tobacco all together. Among them, e-cigarettes are well-recognised for constantly improving in technology since its invention in the early part of this century. 

According to a study in 2018, e-cigarettes was effective in reversing harm resulting from tobacco smoking in COPD patients over a 3-year period. The study found the COPD exacerbations were halved in patients who stopped or considerably reduced their smoking habit following switching to e-cigarettes, and that these beneficial effects may continue in the longer term. Moreover, an evidence update by Public Health England published in 2019 showed that across socio-economic groups, the main reason for e-cigarette use was to quit smoking, and prevalence of e-cigarette use was very low (0.4% to 0.8%) in never-smokers.

Several research studies have been conducted on ANDS over the last years and there was a need to undertake a systematic review and meta-analysis of published scientific literature in order to compare the toxicities of nicotine, other chemicals, and metal ions produced during cigarette smoking vis-à-vis ENDS vaping to objectively evaluate the health and safety aspects of ANDS. Accordingly, we conducted a first of its kind evidentiary review on ANDS in the country. We reviewed 299 published articles in leading peer reviewed journals from the world and, basis our meta-analysis, found that toxic chemicals such as the class 1 carcinogens and carcinogenic metal ions were found to be present in significantly higher quantities in conventional cigarette smoke than in ENDS vapor. In addition, we found that ENDS usage was 4.13 fold higher among former smokers than in non-smokers, while its use was 7.53 times higher among current smokers than non-smokers. 

Notwithstanding the existing gaps in knowledge pertaining to  long-term health effects of ANDS, which needs to be adequately addressed, researched and filled, multiple global agencies, including US-Food and Drug Administration (FDA), US-National Academies of Sciences, Engineering and Medicine (NASEM), American Cancer Society (ACS), UK-Royal College of Physicians (RCP), British Medical Association (BMA), Public Health England (PHE), among others, and Governments of Canada, New Zealand and Philippines have acknowledged the potential of ANDS towards harm minimization of tobacco. Many countries, including UK, New Zealand, Sweden and Canada, which adopted these options into their existing policies of tobacco control, are recording unprecedented declines in the rate of tobacco smoking in last few years. Recently countries such as UAE and Seychelles, which had earlier banned these products, have taken a note of the harm reduction potential of ANDS and have framed regulations to address the costs and benefits analysis adequately. 

The imperative for including technological innovations such as ANDS and tobacco harm minimization as a supplementary tools to our existing arsenal of tobacco control measures should be, in my considered opinion, the collective priority of the public health communities and governments across the globe to adequately and effectively address the scourge of tobacco and its adverse effects. And this applies to India as much, since India bears the 2nd highest tobacco burden in the world.