Tobacco smoking is one the most critical public health challenges that the global community faces today. India is home to approximately 106 million cigarette smokers, accounting for almost 11.2% of the world’s smokers. Tobacco smoking has been linked to cancer, cardiovascular diseases, and respiratory ailments and on an average, 5 people die per minute due to tobacco-related illnesses in India which is one-sixth of the World’s tobacco related deaths.

In Madhya Pradesh specifically, as per the GATS 2 survey, 30-40% of the state’s population uses tobacco in some form. These numbers are higher than the national average of 28.6%. While there has been a modest decline in tobacco use prevalence in the state since 2009-10, there is still a long way to go to reduce the state’s tobacco burden.

To strengthen the commitment and collaboratively work towards decreasing the economic cost of tobacco related illnesses and deaths, Heart Care Foundation of India (HCFI), brought together multiple stakeholders for deliberations on the need for “Tobacco Harm Reduction: A viable alternative to the scourge of combustible cigarettes” in the State.

Dr. K.K. Aggarwal, President, Heart Care Foundation of India (HCFI), while underscoring the importance of evaluating and adopting evolving harm reduction measures said, “India bears a particularly high non-communicable disease burden, and as per WHO estimates, nearly 61% of all deaths in India can be attributed to NCDs, including heart disorders and cancer. Increase in cancer incidence is directly correlated with unhealthy lifestyles, including tobacco consumption, specifically cigarette smoking, which is one of the leading preventable causes of disease and death across the world.”

“Despite efforts to reduce tobacco burden by means of taxation and stringent labelling requirements, cigarette volumes have not witnessed significant decline. Therefore, reduced harm alternatives such as electronic nicotines delivery systems (ENDS) coupled with behavioural counselling need to be made available as there are several smokers who are unwilling or unable to quit with the help of nicotine gums or patches. ENDS are a sui generis product, which can significantly reduce harm among smokers if they completely switch from combustible cigarettes. There is increasing international and local evidence that ENDS or e-cigarettes are considerably less harmful than conventional smoking, with lifetime cancer risk of e-cigarettes is assessed to be less than 0.5% of the risk of smoking”, he added.

While tobacco control has been an active area of interventions by central and state governments using a mix of economic deterrents and awareness efforts, cigarette volumes have been slow to decline. In fact, cigarette volumes are only declining by ~2.2% annually in India, despite prices going up by ~3.5X in the last 8 years. Emphasis on tobacco harm reduction by means of alternatives such as ENDS could play a key role in strengthening India’s tobacco control efforts.

Recently, researchers at the North-Eastern Hill University, Shillong lead by Prof. R. N. Sharan conducted the first-of-its-kind ‘systematic review and meta-analysis on the health and safety implications of ENDS’ and found that toxic chemicals (including class 1 carcinogens and carcinogenic metal ions) were present in significantly higher quantities in conventional cigarette smoke than in ENDS vapor. More importantly, they concluded that ENDS do not inculcate significant vaping habit among non-smokers.

Sharing his views, RN Sharan, Professor, Biochemistry Department-North-Eastern Hill University (NEHU) said, “Tobacco Harm Reduction (or THR) strategies are based on the fact that even though nicotine is addictive, it doesn’t cause harm and has an overall low risk profile. There is growing scientific evidence to support the use of e-cigarettes as a sustainable and more effective alternative to cigarette smoking and that long-term effects of these products will be minimal. In fact, many countries that have regulated ENDS are already witnessing record reductions in smoking rates. In the UK, smoking rate fell to 15% in 2017, reaching its 2025 target eight years earlier and in the US where e-cigarettes are available more readily available, cigarette sales volumes dropped by as much as 5.3% in 2016-17 alone and this downward trend seems to be continuing.”

Last month, Heart Care Foundation of India had released a consensus statement signed by leading medical practitioners, which was also published in the Indian Journal of Clinical Practice. The statement highlighted the harm reduction potential of ENDS basis the available evidence and encouraged formulation of a robust regulatory framework for the category.

The dialogue concluded with an interactive discussion and proposed recommendations on the need for recognising the value of harm reduction tools like e-cigarettes, which can be used by adult smokers to reduce tobacco harm or quit smoking. There was consensus amongst the participants that there is a need for the government to make informed decisions and collaboratively work towards devising a regulatory framework for ENDS that enables India that accounts for the cost and benefits of such products adequately.