E-cigarettes on verge of being banned: Is end of choice the start of safe?

Electronic nicotine delivery system products may be banned across the country. Is this move warranted?

Presented with a choice they had to make, most people would choose the lesser of two evils. Alternatively, they can view the lesser of two evils as being evil still and therefore do everything possible to avoid both.

These contrary choices seem to define the stances taken by the principal stakeholders who are party to the government’s plan to impose a nationwide ban on e-cigarettes. Earlier this month, the health ministry proposed to crack down on electronic nicotine delivery systems (ENDS), which include e-cigarettes, and list them as drugs under the Drugs and Cosmetics Act to prevent their manufacture, sale, distribution and import.

E-cigarettes are by and large considered less harmful than conventional cigarettes but their long-term health impacts aren’t clear. Essentially a handheld battery-powered vaporiser, an e-cigarette simulates smoking and uses an electric charge to vaporise nicotine instead of burning tobacco. Apart from nicotine, flavourings, additives and contaminants, the e-liquid in e-cigarettes usually contains propylene glycol and glycerol, which are mostly considered harmless when inhaled. E-cigarettes contain far fewer chemical compounds compared to cigarettes.

Cigarette smokers are addicted to the nicotine the cigarettes contain, while the tar produced from burning tobacco has most of the carcinogenic and other harmful chemicals found in the smoke. But the nicotine addiction triggered by e-cigarettes also has harmful effects, warn health experts.

E-cigarettes are designed with the promise of offering a similar high to smokers. But while weaning smokers off tobacco, they remain addicted to nicotine, points out Shyam Aggarwal, oncologist at Sir Ganga Ram Hospital in Delhi.

Nicotine, if consumed in large quantities, can be carcinogenic in the long term. While smoking is associated with lung cancer, nicotine addiction can lead to pancreatic and breast cancers, he says. “It is not a safe molecule, and it can affect the brain, heart, and cause gastrointestinal toxicity, nausea, vomiting, diarrhoea and burning of eyes.”

A 2015 article published in the Indian Journal of Medical and Paediatric Oncology (“Harmful Effects of Nicotine”) points out that while nicotine is considered a safer alternative to tobacco, it poses an increased risk of cardiovascular, respiratory and gastrointestinal disorders. It added that many studies had consistently demonstrated the carcinogenic potential of nicotine, and called for regulation of its use and sale under the supervision of medical personnel.

Proponents of a ban on e-cigarettes flag the high risk of addiction among youths.

Monika Arora, director, health promotion division, and additional professor, Public Health Foundation of India, explains that the brain keeps developing till the age of 25. “Nicotine changes the way synapses are formed and can harm the parts of the brain that control learning and is responsible for decision-making and impulse control. Use of e-cigarettes in adolescents and youths poses a unique risk as evidence is pointing to how e-cigarette users have progressed to become conventional cigarette users,” she says.

Arora adds that data from the Global Adult Tobacco Survey-2 (GATS-2, 2016-17) clearly show that India has not been able to effectively regulate smokeless tobacco. “We cannot afford to introduce a new addiction, especially one which will adversely impact the health of our vulnerable adolescents and youth.”

A study by Delhi-based NGO, Health Related Information Dissemination Amongst Youth (HRIDAY), found that knowledge and awareness about e-cigarettes and e-hookahs (also classified under ENDS) was highest among college students, followed by schoolchildren, teachers and parents. It also revealed rampant exposure among the young to promotional campaigns, particularly through online portals and e-commerce sites; and 36 per cent of points of sale covered in the study reported sale of ENDS to minors. Evidence to classify e-cigarettes as cessation products is weak. In fact some reviews highlight that e-cigarettes reduce cessation rates, says Arora.

More than one billion people smoke cigarettes globally, with India accounting for 11.3 per cent of the smoking population. The tobacco and cigarette industry is a big contributor to the Indian government’s tax revenue, with over Rs 34,000 crore annually. The ENDS market is worth under Rs 300 crore.

In India, 12 states have already banned the use and sale of e-cigarettes, e-hookahs and vapes. (A little larger than an e-cigarette, a vaporiser, or vape, offers longer battery life and uses a rechargeable module. E-hookahs, like e-cigarettes, allow the user to inhale a vapour that may contain nicotine and other flavours and chemicals.)

Last August, the health ministry issued an advisory to all states and union territories to ban ENDS. It was later challenged in the Delhi High Court, which ruled that it not be binding on states and government bodies. The government plan to now ban ENDS followed the release of a white paper on the products by the Indian Council of Medical Research (ICMR) last month. It cited the increasing use of ENDS by youths and adolescents and studies claiming that such users are more likely to take to regular cigarettes. It also conceded that potential short- and long-term health risks of ENDS are yet to be determined while recommending “complete prohibition in the greater interest of protecting public health”.

Ravi Mehrotra, former director of the National Institute of Cancer Prevention and Research and a member of the writing committee of the paper, says vaping has become a rage in the West, especially the US where the brand Juul has over 70 per cent share of the e-cigarette market. Recently Juul’s CEO apologised to parents of teens who vape, saying the product is not intended for them.

Mehrotra argues that major tobacco companies are trying to convert tobacco addiction into nicotine addiction. “It is like wanting to jump off the third floor of a building rather than the tenth.” He says that there isn't adequate research to say that vaping is safe, although he admits it is safer than the tar and nitrosamines present in tobacco. While welcoming further research on e-cigarettes, he says the best option is to quit smoking and opt for a cessation aid that is completely innocuous.

Smoking is seeing a decline globally. Vaping, meanwhile, has spawned a trend and found its way to popular culture — recall Johnny Depp in The Tourist (2010). India witnessed a six per cent decrease in tobacco consumption among users aged 15 and above from 2009-10 (34.6 per cent) to 2016-17 (28.6 per cent). But at the current rate of decline in tobacco use, it will still take many more years to come close to eliminating the problem, asserts Samrat Chowdhery, director of the Association of Vapers India (AVI). He adds that banning e-cigarettes won’t help arrest the number of tobacco deaths, which stands at more than a million annually in India.

A former journalist, Chowdhery was a long-time smoker who quit after many failed attempts when he turned to vaping nearly five years ago. He began lobbying for vaping after an e-cigarette ban in Karnataka in 2016. AVI has fought a legal battle and has been pushing for regulation. He accuses the government of issuing a “draconian research gag” — asking state-funded institutions to consult the health ministry before publishing research — just before the release of the ICMR white paper, which he claims has cherry-picked facts.

“The harm from smoking comes from combustion that produces tar, which contains carcinogenic chemicals. In vaping, there is no combustion. There are toxins, however, at a much reduced level, and anyone who has been a smoker knows it is much safer,” he says.

AVI is keeping up the pressure on governments, including in Delhi, to opt for regulation. Among studies, it has cited a review by Public Health England this year, which “reinforces the finding that vaping is a fraction of the risk of smoking, at least 95 per cent less harmful, and of negligible risk to bystanders”, and the UK’s Royal College of Physicians, which says “available data suggest that e-cigarette health risks are unlikely to exceed 5 per cent of those associated with smoked tobacco products, and may well be substantially lower”.

“We are not in this war between the tobacco control groups and the industry. Vapers are being made pawns. For us, these products should be available and at affordable prices,” says Chowdhery. He acknowledges that teen vaping is a problem, and that action should be taken to prevent it, but not in the form of a blanket ban. “I am all for proper labelling and communication about nicotine causing dependence and not being suited for long-term use.” Besides, he feels, bans are ineffective and breed underground markets with no oversight.

Being a part of a segment driven by technology, new-generation ENDS products include in-built features that help monitor use. For instance, Chowdhery says, vape pens with biometric scanners that can verify age or ones with a Bluetooth lock are already available. Also, unlike conventional cigarettes, ENDS products offer the option of smoking without nicotine. 

Clear as mud? Quite right.