Globally, almost a third of tobacco consumers use oral products. Smokeless tobacco (SLT) is generally safer than combustibles. But traditional forms popular in South Asia pack a deadly punch, leading to more than 570,000 annual deaths. Despite these products causing 88 percent of SLT-related mortality, the World Health Organization (WHO) and its allies continue to club them alongside much safer SLT options under the risk-blind “all tobacco is bad” paradigm. This funnels interventions into narrow quit strategies and forestalls harm reduction.
About 10 million people use SLT in Pakistan, comprising over 40 percent of overall tobacco use. Common products range from paan to gutka to naswar—all of which have been proven to be deadly.
In contrast, snus, a steam-pasteurized Scandinavian oral tobacco that is used by placing between the upper lip and gums, has long been known to carry far lower harms. In 2019, the US Food and Drug Administration (FDA) authorized risk-reduction claims to be made about some snus products. Meanwhile a modern variant, nicotine pouches, contains no tobacco and ranks even lower on the continuum of risk.
Both offer significant potential as safer substitutes to harmful SLT. Their efficacy remained to be demonstrated in a real-world South Asian setting, but that’s rapidly changing. Last week, new industry figures showed that Velo, a nicotine pouch product, had hit sales of 40 million pouches a month in Pakistan.
“Product substitution has been shown to be the most effective strategy ever used to reduce the death and disease toll from toxic tobacco products.”
Such rapid substitution—Velo launched in Pakistan only in early 2020—is clear evidence that despite the cultural, social and price adhesiveness of traditional smokeless products, harm reduction here is possible.
“Product substitution has been shown to be the most effective strategy ever used to reduce the death and disease toll from toxic tobacco products,” David Sweanor, an independent tobacco industry expert and adjunct professor at the University of Ottawa, told Filter. “The evidence from wealthy countries such as Sweden, Norway, Japan, the UK and New Zealand is stunning. The role of modern oral nicotine now puts the lie to those claiming substitution is not viable in lower-income countries.”
In Sweden, adults have largely replaced cigarettes with snus over the past few decades, and the government recently announced that smoking rates in the country have declined to 5.6 percent. In 2021, the UK—which has largely promoted vapes as tobacco harm reduction (THR)—recorded its lowest ever smoking rate. Although Japan has been hostile to e-cigarettes, it has almost begrudgingly welcomed “heat-not-burn” tobacco products, and has seen close to a 43 percent drop in cigarette smoking in half a decade.
Lower- and middle-income countries, which bear the brunt of the world’s tobacco-related harms, could well be next.
Nihar Dholakia is steering his family’s century-old smokeless tobacco business in Gujarat, India, toward safer alternatives.
Even some traditional SLT manufacturers in South Asia are beginning to see the value proposition of modern oral products. Among them is Nihar Dholakia, who is steering his family’s century-old SLT business in Gujarat, India, toward safer alternatives.
“India has a long history of using smokeless tobacco in the form of dipping and chewing,” he told Filter. “Modern oral nicotine pouches, or tobacco-free snus, can play a massive role in helping ease the oral cancer burden in India. In the last two years of their presence in Pakistan, the use of toxic SLTs like gutka and naswar has dropped to a record low as exports of these goods to Pakistan from India have dipped. We may see the same in the Middle East and in parts of Africa soon.” (Eighty to 90 percent of oral cancers in India are attributed to SLT use.)
Yet the transformation that’s happening in Pakistan, like almost everywhere else, is occurring not with government support but in its absence.
“Currently, nicotine pouches are being sold and used in Pakistan in a regulatory vacuum,” Arshad Ali Syed, the head of the Alternative Research Institute (ARI), a research group based in Islamabad, told Filter. “We believe there is a need for sensibly regulating tobacco harm reduction products, including e-cigarettes, nicotine pouches and heated tobacco products. Additionally, the regulation should be appropriate to the risk these products pose to human health.”
Neighboring India, where there are more than 200 million SLT users—double the number who smoke—is also yet to regulate for a harm reduction approach. That’s despite 350,000 annual deaths attributed to SLT use, and a recent parliamentary standing committee report highlighting the need to focus on SLT interventions. India banned the sale of e-cigarettes and heated tobacco products in late 2019.
“Reduced-risk oral tobacco substitutes are the key to lowering the burden of death and suffering, especially in socially and economically disadvantaged groups.”
“The Southeast Asian region has the highest proportion of people who use harmful oral tobacco mixed with additives,” Dr. Kiran Melkote, a Delhi-based member of Association of Harm Reduction Education and Research (AHRER), told Filter. “This also tends to be concentrated among the socially and economically disadvantaged groups.”
A major roadblock to product substitution is the stance taken by the WHO and its allies, who have routinely called for bans on emerging nicotine alternatives, irrespective of their risk profiles and potential to reduce high tobacco mortality and morbidity in the region. Recently, they opposed the approval sought by Pakistan’s health ministry for heated tobacco, while their pressure on the Indian government to enact its bans is well known, and there are ongoing efforts to get them banned in Bangladesh.
“Instead of continuing counterproductive efforts to block substitution, it is time for global tobacco control groups to embrace and enhance such interventions,” Sweanor said.
But so far, there appears to be less opposition to novel and risk-reduced oral products. That could be because, despite the enormity of the toxic SLT problem, the policy focus of governments and abstinence-oriented groups remains on combustibles. Further, the South Asian oral tobacco industry is unorganized and, in many cases, run with politicians’ direct or indirect participation—giving businesses protection from taxes, interventions and competition from the organized sector. Whether that situation lasts remains to be seen.
“The Swedish experience has shown the way—reduced-risk oral tobacco substitutes like snus and nicotine pouches are the key to lowering the burden of death and suffering, especially in socially and economically disadvantaged groups,” Dr. Melkote said. “It is time the governments take notice and start subsidizing and substituting these products on a large scale as part of the national tobacco control programs.”
Photograph of the Pakistan Monument in Islamabad by Yaarahmadd via Wikimedia Commons/Creative Commons 4.0
Both INNCO, of which the author was previously president, and The Influence Foundation, which operates Filter, have received grants from the Foundation for a Smoke-Free World. The Influence Foundation has also received grants from Reynolds American, Inc., a subsidiary of the manufacturer of Velo. Filter’s Editorial Independence Policy applies.
