Above: Smokers who can’t quit may be encouraged to switch to e-cigarettes

Photo credit: Vaping360.com

The health ministry has issued an advisory not to allow the sale of Electronic Nicotine Delivery Systems, though these are far less harmful than conventional cigarettes

~By Dr KK Aggarwal

That tobacco kills is a fact. Globally, more than 60 lakh of these deaths are the result of direct tobacco use, while around 8.9 lakh are due to non-smokers being exposed to second-hand smoke. Smoking-related deaths are expected to increase to 80 lakh by 2030. Hence, it is important to reduce it, otherwise an estimated one billion lives will be lost prematurely by 2100, according to the Annual Review of Public Health. And this is where e-cigarettes come in.

In 2003, the World Health Assembly, the decision-making body of the WHO, adopted the Framework Convention on Tobacco Control (FCTC). Implemen­tation of the FCTC in all countries has been included in Sustainable Development Goal 3 of the WHO. And one of the goals relates to tobacco. It says: “By 2030, reduce by one-third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being.”

So what kills—nicotine or the tar in cigarettes? Nicotine is highly addictive and this is why people give in to the urge to smoke. But, more than nicotine, it is the smoke that is harmful as it contains carcinogens and toxins that come from combustion of tobacco. That in­cludes tar and carbon monoxide. According to the British Medical Journal: “People smoke for the nicotine, but they die from the tar.” Therefore, we should ban tobacco, but if we can’t, we should at least reduce its harmful effects.

Harm reduction is integral to the definition of tobacco control as specified in Article 1(d) of WHO FCTC. It defined “tobacco control” as “a range of supply, demand and harm reduction strategies that aim to improve the health of a population by eliminating or reducing their consumption of tobacco products and ex­po­sure to tobacco smoke”. Simply put, to­bacco harm reduction means action taken to reduce the health risks associated with the use of tobacco or nicotine. It involves the use of non-combustible products such as vaping ones like e-cigarettes, heated tobacco products or smokeless tobacco. These products are collectively called Alternative Nicotine Deli­very Systems (ANDS) and do not involve burning of tobacco leaf or smoke inhalation.

A report, “Nicotine without smoke: tobacco harm reduction”, by the Tobacco Advisory Group of the Royal College of Physicians published in 2016, concluded that “e-cigarettes are likely to be beneficial to UK public health. Smokers can therefore be reassured and encouraged to use them, and the public can be reassured that e-cigarettes are much safer than smoking”.

An expert review of e-cigarettes published by Public Health England, the United Kingdom’s largest public health agency, in February this year states that vaping poses only a small fraction of the risk of smoking and switching completely to it conveys substantial health benefits. It said that e-cigarettes could be contributing to at least 20,000 successful new quits per year and possibly many more. It also says that less than 10 percent of adults understand that most of the harmful effects from smoking are not caused by nicotine. More significantly, it says that evidence does not support the concern that e-cigarettes are a route to smoking among young people.

A UK parliamentary inquiry into e-cigarettes reported on August 17, 2018, that “e-cigarettes present an opportunity to significantly accelerate already declining smoking rates, and thereby tackle one of the largest causes of death in the UK today. They are substantially less harmful—by around 95 percent—than conventional cigarettes. They lack the tar and carbon monoxide of conventional cigarettes—the most dangerous components. It has also proven challenging to measure the risks from ‘second-hand’ e-cigarette vapour because it is negligible and substantially less than that of conventional cigarettes”.

David B Abrams from the College of Global Public Health, New York University, writes in the April 2018 issue of Annual Review of Public Health: “A diverse class of alternative nicotine delivery systems (ANDS) has recently been developed that do not combust tobacco and are substantially less harmful than cigarettes. ANDS have the potential to disrupt the 120-year dominance of the cigarette and challenge the field on how the tobacco pandemic could be reversed if nicotine is decoupled from lethal inhaled smoke. ANDS may provide a means to compete with, and even replace, combusted cigarette use, thus saving more lives more rapidly than previously possible.”

But what is the WHO stand on these systems? It has described all forms of tobacco use as harmful, including heated tobacco products, and is sceptical about the effectiveness of ANDS as effective tools for quitting. It is of the view that “with almost 8,000 different flavours added, including fruit and candy-like flavours, there is legitimate concern that instead of reducing the number of smokers, they will actually serve as a gateway to nicotine addiction, and ultimately, smoking, particularly for young people”. Hence, it advocates policy and regulatory measures for these products.

India, being a signatory to the WHO FCTC, is bound by its policies. On August 28, 2018, the Union health ministry, instead of banning tobacco in all forms, banned the sale of e-cigarettes in India and issued an advisory: “The states/Union territories are advised, in larger public health interest and in order to prevent the initiation of ENDS by non-smokers and youth with special attention to vulnerable groups, to ensure that any Electronic Nicotine Delivery Systems (ENDS) including e-Cigarettes, Heat-Not-Burn devices, Vape, e-Sheesha, e-Nicotine Flavoured Hookah, and the like devices that enable nicotine delivery are not sold (including online sale), manufactured, distributed, traded, imported and advertised in their jurisdiction. And whereas, there are possibilities that children, adolescents & youth (and generally non-smokers) will initiate nicotine use through ENDS at a rate greater than expected if ENDS did not exist; and that, once addicted to nicotine through ENDS, such children, adolescents & youth are likely to switch to cigarette smoking.”

The ministry cited lack of scientific evidence regarding the effectiveness of ENDS as a smoking cessation aid and said that they are “not yet approved as Nicotine Replacement Therapies (NRTs) under the Drugs and Cosmetics Act”.

On September 12, the US Food and Drug Administration (FDA) also cautioned that the use of e-cigarettes among the youth has reached an epidemic proportion and this “clear and present danger” must be stemmed. The FDA said: “While we remain committed to advancing policies that promote the potential of e-cigarettes to help adult smokers move away from combustible cigarettes, that work can’t come at the expense of kids. We cannot allow a whole new generation to become addicted to nicotine.”

The American Heart Association, in a statement, concurred with the FDA regarding the concern about use of e-cigarettes among the youth. It also urged the FDA to take immediate and impactful action regarding the epidemic of youth tobacco use. The American Academy of Paediatrics even rejected the 60-day period allotted by the FDA to the e-cigarette manufacturers and urged it “to use its existing authority to immediately regulate all e-cigarettes”.

However, the Heart Care Found­ation of India (HCFI) feels that based on available evidence, using e-cigarettes is less harmful than smoking cigarettes though the health effects of its long-term use are not known.

It has always supported any smoker who is considering quitting, no matter what approach they use. To help smokers quit, it recommends that clinicians advise their patients to use Drug Controller General of India-approved cessation aids that have been proven to support successful quit attempts.

While many smokers will choose to quit smoking without the assistance of a doctor, some will opt to use e-cigarettes to accomplish this goal. HCFI recommends that doctors support all attempts to quit the use of combustible tobacco and work with smokers to eventually stop using any tobacco product, including e-cigarettes. Some smokers, despite firm advice from the doctor, will not attempt to quit smoking cigarettes and will not use approved cessation medications. These individuals should be encouraged to switch to the least harmful form of tobacco product possible. Switching to the exclusive use of e-cigarettes is preferable to continuing to smoke combustible products. However, these individuals should be regularly advised to completely quit using all tobacco products. The HCFI also strongly discourages the concurrent use of e-cigarettes and combustible cigarettes, a behaviour that is far more detrimental to a person’s health.

So don’t start using any tobacco product. And if you have, shift to less harmful forms.

                                            —The writer is president, Heart Care Foundation of India, and immediate past national president, Indian Medical Association