India has the second largest population of tobacco users in the world. Nearly 270 mill ion Indians use tobacco products, and smoking remains one of the leading causes of premature death and disease in India and the world. India has made great strides in tobacco control over the past 20 years. For example, India prohibited advertising of tobacco products and prohibited the sale of tobacco products to and by people under 18 years of age. These and other measures have led to decreasing tobacco use rates over the past decade. Nevertheless, India is missing a critical tobacco control opportunity.
In addition to other tobacco control measures, an idea known as tobacco harm reduction can help smokers who cannot or do not want to quit smoking transition to less harmful products. Products such as e-cigarettes, heated tobacco products, snus and nicotine pouches are examples of tobacco products that pose substantially lower risk of harm to users. However, having banned e-cigarettes and other electronic nicotine delivery systems nearly two years ago, India has effectively eliminated the opportunity to incorporate these products into a comprehensive tobacco control program.
Many countries have recognized that well-regulated, reduced-risk tobacco products can improve population health and decrease smoking rates. Japan has seen smoking rates decline at unprecedented levels since the introduction of heated tobacco products. The United Kingdom explicitly embraces tobacco harm reduction as part of its tobacco control strategy. The United States Food and Drug Administration recognizes that tobacco products exist on a continuum of risk with combustible products representing the highest risk.And, New Zealand recently reversed its ban on e-cigarettes and heated tobacco products with a law designed to achieve a “smoke-free New Zealand” by 2025.
Indeed, even the World Health Organization’s Framework Convention on Tobacco Control (FCTC), the preeminent global tobacco control plan that India ratified in 2004, states that tobacco control includes harm reduction strategies that eliminate or reduce exposure to tobacco smoke. As a leader in tobacco control in Southeast Asia, India has played a key role in implementing and promoting the FCTC in the region. Using this leadership position, India has the opportunity to set the tone for responsible and effective regulation of reduced-risk products that protects public health.
Responsible, effective regulation can take many forms. Minimally, ingredient and product lists should be filed with governmental regulatory agencies to ensure the safety of products on the market. Additionally, implementing a taxation structure for all tobacco products that is risk-proportionate can encourage people who use tobacco to choose less harmful alternatives. Specifically, a risk-proportionate taxation structure would tax reduced-risk products at lower levels than combustible products. Making reduced-risk products less costly than combustible products would provide incentive for people who use tobacco to choose less harmful products. Another benefit of increasing taxes on existing tobacco products and adding, and taxing, new categories of tobacco products is that this will generate more revenue that can go toward cessation programs. Other regulations that would be vital with the introduction of reduced-risk products include enforcing minimum age of purchase laws to prevent young people from accessing tobacco products and regulating advertising.
Despite the ban on e-cigarettes there is evidence that some Indians are already using e-cigarettes for harm reduction. A 2020 survey of 3000 Indian e-cigarette users provides an idea of how e-cigarettes are currently being used in India. This study provided some interesting findings from a harm reduction perspective. For one, most e-cigarette users had smoked boxed or roll-your-own cigarettes prior to using e-cigarettes. This suggests that, overall, e-cigarettes are not serving as an on ramp to tobacco use. The other promising finding was that after initiating e-cigarette use, 30 percent of participants quit smoking and 38.8 percent quit using smokeless tobacco products. Another 41 percent of participants reported reducing their smoking and 30 percent reported reducing their smokeless tobacco use. Since e-cigarettes are significantly less harmful than combustible tobacco and many smokeless products, switching from other tobacco products to e-cigarettes will benefit public health.
Done thoughtfully and responsibly, the Indian government and the Indian people could see great benefits from reversing the ban on e-cigarettes and heated tobacco products. In addition to decreasing the premature death and disease associated with tobacco use, increased tax revenue could be used to expand cessation programs. As India looks to reduce the burden of non-communicable diseases, it—like New Zealand, the United Kingdom and others—may want to rethink its current prohibition and adopt science-based regulation of safer alternatives to smoking.
Chelsea Boyd is a fellow in the R Street Institute’s Integrated Harm Reduction policy area. Her work at R Street focuses on researching and advancing policy that supports harm reduction in the areas of sexual health, tobacco and intravenous drug use.
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