India’s new e-cigarette ban goes against its history of being a leader in harm reduction for Asia
India is no stranger to harm reduction — the philosophy that idea that risky actions or behaviors can be made safer without requiring abstinence, which is often difficult to achieve. In the opioid realm, for instance, leaders have embraced ways to improve the lives of people who use drugs. Syringe access programs for the nation’s 200,000 to 1 million citizens that inject drugs are increasing; over 200 sites now offer methadone as an alternative to dangerous opioids for citizens that use them. One state – Manipur – allows for peer distribution of naloxone to reverse opioid overdose. This approach not only decreases the transmission of infectious diseases, it increases opportunities for users to transition away from dangerous opioids. All of this has led to increased surveillance of drug use patterns to help contain health crises and increased opportunities for people who use drugs to access treatment, all without encouraging drug use in people who would otherwise not use them. Yet when it comes to the harm-reduction benefits of e-cigarettes, officials have turned a deaf ear.
How many of India’s leading public health authorities came to the conclusion that e-cigarettes are as dangerous, if not more so, than combustible cigarettes is baffling. Comprehensive studies examining the harmful chemicals, exposure and health outcomes led the United States National Academies of Sciences, Engineering and Medicine to conclude that “completely substituting e-cigarettes for combustible tobacco cigarettes reduces users’ exposure to numerous toxicants and carcinogens” and “results in reduced short-term adverse health outcomes in several organ systems.” In fact, researchers have found that switching can lead to improvements lung function and reduced exacerbation of COPD symptoms. The United Kingdom’s Royal College of Physicians estimates that e-cigarettes are unlikely to exceed 5% of the risk associated with combustible cigarettes. What’s more, using e-cigarettes also helps people quit smoking altogether, with twice the success rate of other quit methods. Conversely, there is no evidence that banning e-cigarettes will improve public health. The good news is that there a better way to enable a healthy populace than to simply ban the issue away.
First, officials should create opportunities for people to switch to a safer form of tobacco consumption. In the spirit of protecting the health of their citizens, governments arguably have a duty to promote safer alternatives of consumer products — especially when extremely dangerous products like combustible cigarettes are freely available. E-cigarettes certainly fall into this “safer alternative” category. And to ensure that e-cigarettes remain relatively safe, officials should implement robust manufacturing standards that help to ensure product safety and retail standards that limit adolescents’ access to the product.
Second, officials should do everything they can to reduce the likelihood that consumers will be exposed to more dangerous, black market products. Banning a highly in-demand product like e-cigarettes will do the reverse. In the United States, the media have been busy covering “vaping illnesses” that, to date, have claimed five lives. It is important to note that these deaths were not caused by government-approved products, but by THC-containing e-liquids sold on the black market. No illnesses or deaths have resulted from use of legal and regulated nicotine-containing e-cigarettes. Yet banning e-cigarettes — which are currently used by 38 million Indian citizens — will force the market underground. Absent government regulation, the nicotine-containing e-cigarettes sold through these black markets could contain dangerous chemicals that result in severe and acute illnesses.
Third, instead of banning e-cigarettes, officials should lead public health campaigns that encourage smokers who cannot or do not want to quit to switch to less harmful alternatives. In 2017, the U.K.’s Public Health England included e-cigarettes in its annual “Stoptober” quit smoking campaign. By accepting that e-cigarettes are much less harmful that combustible cigarettes and can act as a smoking cessation device, these efforts have led to increased quit attempts among the public and more success in abstaining from smoking in the long term. On the other hand, insisting that e-cigarettes are as dangerous as combustibles will only deter people from using this safer alternative.
There are 100 million smokers in India — most of whom will live with chronic illnesses and die prematurely as a result. These people, and the 38 million who use e-cigarettes, are owed more than a dismissive ban of a product that has proven itself to be safer than combustible cigarettes and more effective in helping people quit smoking altogether than current quitting tools.