Tobacco is India’s Trojan horse. It was brought to our shores five centuries ago on Portuguese ships. Indians readily took it in as a trade good, then farmed it in abundance for its assumed medicinal properties. They developed a multitude of ways to consume it, until it unleashed death and destruction on a scale the nation had never experienced before.
This country is now home to an estimated 12 percent of the world’s billion cigarette smokers. Yet even this vast group is only the tip of the iceberg. India has a larger population who smoke local variants of tobacco. These include: bidis, cigarette-like rolls of unprocessed tobacco wrapped in a tendu or temburni leaf; hookah; chilam, a traditional clay pipe; and other forms. Many more people chew tobacco, in forms known as khaini, zarda and gutkha, which avoid some major consequences of smoking, like lung cancer, but still carry significant risks.
Altogether, 29 percent of Indians—about 270 million people, not far off the population of the United States—use tobacco in some form. This figure comprises 42 percent of men and 14 percent of women, making Indians the second largest tobacco-consuming population in the world after China—and given our projected population growth, we could before long take an unwanted lead over our neighbor. We currently bear an enormous health burden of over a million tobacco-related deaths annually, with $22 billion in economic loss.
This massive human tragedy will worsen if we don’t act. But worse still than inaction, the government of India—just recently, more than ever—appears determined to behave in ways that prevent reduction of smoking-related harms.
The first problem is simply a lack of urgency from the Indian state. Although a number of WHO-recommended tobacco control measures have been implemented, and they have led to an absolute reduction in tobacco prevalence of 6 percent over a seven-year period between 2010 and 2017 (according to Global Adult Tobacco Surveys 1 and 2), this is hardly enough. If this fall is not substantially accelerated, it will take almost a century to eliminate tobacco use, in which time many millions more lives will be lost.
India had the lowest quit rates among the countries surveyed in GATS-2 (followed by Indonesia) and though there is an overall decline in use, the disease demography shows tobacco is becoming a bigger killer. Ischemic heart disease and chronic obstructive lung disease, both attributable to tobacco, ranked in positions one and two among causes of death in India in 2016, having ranked sixth and eighth respectively in the 1990s.
At present there are three main lines of state-sanctioned interventions: encouraging cold-turkey quit attempts, cessation services and counseling, and nicotine replacement therapy (NRT). These are not enough. Nationwide quit lines and media outreach have done little to change the 95 percent failure rate of willpower-led cessation. Tobacco cessation clinics remain woefully inadequate, with just 19 functional at present. The effectiveness of NRTs is also limited, hovering near 7 percent.
That favorite measure of policymakers, raising taxes, also has limitations in a country like India with a wide spectrum of popular tobacco products. For instance, raising costs of cigarettes above a certain level forces smokers to shift to cheaper, more harmful variants, thus causing more harm than good. High taxes do little to limit uptake either, when the average cost of loose cigarettes—in practice sold everywhere, although a few states have issued futile bans—is extremely low.
Instead of heralding the public health opportunity THR provides, the influential tobacco control community has put up stiff resistance.
In this environment of non-existent and low-performing interventions, it is important to consider measures that are showing potential elsewhere. Key among them is tobacco harm reduction (THR). This pathway requires only the moderate effort of sensible regulation, with the market and users’ desire for a healthier life doing the rest.
We practice harm reduction all the time in our everyday lives, from switching to safer food habits to driving more eco-friendly cars, and this evidence-based concept is becoming increasingly prevalent in addiction treatment for other drugs.
Electronic Nicotine Delivery Systems (ENDS), such as e-cigarettes, which eliminate the tar produced by combustion of tobacco leaves, have been found to be around 95 percent safer than smoking. Swedish snus, a non-combustible form of tobacco that is placed behind the lip, has been shown by long-term epidemiological studies to also be a greatly risk-reduced alternative.
However, instead of heralding the public health opportunity THR provides, the influential tobacco control community, in India as in much of the world, has put up stiff resistance to its use. This community includes institutions such as the Indian Medical Association, the National Tobacco Control Programme, and the Public Health Foundation of India. There is a high human cost to this “moral” opposition when tobacco use—above all, smoking—is the world’s leading preventable cause of death.
This hardened and evidently anti-people position is a blowback from decades spent fighting the tobacco industry, which undoubtedly has tried all manners of dirty tricks to sell its products, leading to heightened suspicion towards any measure other than total abstinence from nicotine.
However, as with most industries, technology has changed the landscape, which requires a pragmatic recalibration of strategies and an imaginative recognition of opportunities that did not exist before.
In India this opposition has been especially bullheaded. Snus is effectively banned; when companies applied for licenses to produce it, permission was denied because snus is bizarrely classified as a food product, and use of tobacco in any food product is illegal under existing laws.
Then, just last month, the central government issued an advisory to states proposing an outright ban on ENDS. Among the reasons cited were the “harmful” effects of nicotine and fears of teen use. This appears to have be taken out of the old anti-tobacco playbook, but without adjusting for risk-appropriateness and the concept of harm reduction—perhaps because it requires coming to terms with the fact that mitigating harm is a lot more achievable and, therefore beneficial in practice, than being focused on completely eliminating use. Many working in drug addiction treatment (in international contexts, if not so much in the US) jumped this moral hoop long ago, but people in tobacco control, which impacts far more lives in India, unfortunately have not.
For as long as the Indian state’s interests don’t align with those of the Indian people, it falls on the latter to advocate for reason.
There are yet more hurdles. The tobacco industry claims to provide sustenance for 50 million households in India, which includes widespread farming of the cash crop. Add the government’s approximate 30 percent stake in the country’s largest tobacco company, ITC, along with its high dependence on tobacco taxes, and action becomes even more difficult.
It is worth highlighting that ITC’s stock price shot up on the news of the central advisory against ENDS, as investors felt reassured by state action to keep competing alternatives out of the market. (Although ITC has one ENDS product, Eon, its shortcomings and lack of popularity mean the company has no significant foothold in this space.)
Little forward movement on promoting lower-risk alternatives to curb tobacco use is possible until the state can be separated from tobacco commerce. This is a problem which the WHO Framework Convention on Tobacco Control (FCTC) has highlighted—Article 5.3 states, “Parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law”—but not strictly enforced. The most glaring infractions are by the governments of Asian countries with some of the world’s highest rates of tobacco use, and the most urgent need for lower-risk alternatives.
For as long as the Indian state’s interests don’t align with those of the Indian people, it falls on the latter to advocate for reason and workable solutions to our tobacco epidemic. Even those of us who work in this field often feel incredulous that the biggest obstacle to public health remains those who have been tasked to protect it.
Amid these major challenges, the GATS-2 survey estimates that India already has about 260,000 ENDS users. Imagine how many they could become in more favorable conditions—and the corresponding preservation of life and health.
Encouragingly, while the motivation to quit, particularly for low-income groups, is low, there is nonetheless widespread public awareness of the harm caused by tobacco use. India is also a large producer of medicinal nicotine used in e-liquids, which can help in keeping costs down. Experience elsewhere show that adoption of ENDS is highest in lower-income populations because of their cost-effectiveness.
There is thus every reason to believe tobacco harm reduction can become a huge success story in India—if only better, pro-people policies will allow these lifesaving products to become widely available and affordable.
Photo via Palash Jain/Unsplash