At the cusp of a dramatic shift, India has healthcare battles to fight on multiple fronts. For a country that spends only 1.3 percent of its GDP on healthcare, the swell in numbers of cancer-related deaths in the country is more than just alarming. In 2018, India became the second largest consumer of tobacco in the world, with over 1.35 million people dying of tobacco-related illness each year.
One of the most common types of cancer in India, lung cancer, accounts for 5.9 percent of all new cancer cases diagnosed in the country. Tobacco consumption is a major contributory factor in nearly 95 percent of lung cancer cases and causes other serious health complications.
Studies by the American Cancer Society have conclusively proven that combustible tobacco products are the single largest cause of cancer. Unfortunately, despite enacting several tobacco control measures, the decline in cigarette consumption in India has not been able to meet the intended target.
Cigarette volumes are only declining by 2.2 percent annually in India, despite prices going up by 3.5 times in the last eight years.
India’s multi-layered tobacco crisis extends from the availability of low-priced smoking products to the cobwebs of sluggish regulations. From production to manufacturing, consumption to exports, India’s fight against tobacco is plagued by weak regulatory policies. At this juncture, India needs policies backed by robust scientific evidence to tackle the tobacco menace. We need regulatory reforms backed up evidence-led studies to work towards a solution that creates an impact.
Turning to Science for Solutions
It is essential to understand the behavioural and lifestyle patterns of patients to address the problem. Cigarettes expose smokers to a deadly cocktail of chemicals, carcinogens, and respiratory toxicants, which are by-products to the burning of tobacco. Smoking damages airways and alveoli (air sacs) in the lungs, causing lung cancer and Chronic Obstructive Pulmonary Disease (COPD), which includes lung conditions like emphysema, chronic bronchitis, and inflammation. Even though the nicotine inhaled from smoking tobacco is highly addictive, it is primarily the toxins and carcinogens in tobacco smoke – not the nicotine – that cause illness and death.
If we chronicle the history of anti-tobacco campaigns, from raising taxes to strategies emphasizing tobacco abstinence, countless efforts have failed at reducing the number of smokers. The solution to tobacco consumption is often confined to one word—quit. While there is no denying that quitting may be the most desirable outcome to safeguard the health of smokers, how do we treat those who cannot quit? The answer—evidence-based solutions.
What do You Do When You Can’t Quit?
In the case of long-term smokers, where there is a dependency on nicotine, quitting is not always a viable option. For someone who has been smoking for years, conventional ‘quit smoking’ policies offer little help. In most cases, people do not have the will to quit. We need tobacco harm reduction (THR) strategies, which involve the use of alternative sources of nicotine. THR is extensively being embraced by many countries, to reduce the potential risks associated with tobacco use.
The objective is to look at the scientific evidence and delve deeper into solutions that have worked for countries around the globe. Take, for instance, Electronic Nicotine Delivery Systems or ENDS provide an alternative source of nicotine and reduces the user’s exposure to tar, carcinogens, and toxins that are found in cigarette smoke.
There is a general failure to differentiate between e-cigarettes and combustible tobacco cigarettes. As a result, the same restrictions are often placed on both. There is also an attempt to classify e-cigarettes as tobacco products due to nicotine extracted from tobacco. This decision is unreasonable and has no scientific basis.
A rapid reduction of smoking prevalence is seen in countries where the tobacco harm reduction principle, including regulating ENDS, has been integrated with existing tobacco control policies.
Even though the global debate on the safety and health impact on ENDS continues, there is enough emerging evidence to show that these products are significantly less harmful than cigarettes. The UK and Canada, along with many other world governments, have long been aware of the negative health impact of cigarette smoking and have acted accordingly. However, they viewed ENDS as a positive means to help solve the public health crisis through thoughtful regulation, rather than an outright ban. According to NHS, UK Smoking rates and tobacco related deaths are now at their lowest ever level and continue to decrease (Source: NHS, UK).
Public Health England actively recommends ENDS as an alternative for adult smokers looking to quit because their research shows that it is 95% less harmful than traditional smoking.
In fact, some countries like New Zealand have gone beyond mere regulation and have launched programmatic interventions for informing citizens about the benefits and potential harmful impacts of vaping. In pursuit of its goal to make New Zealand smoke-free by 2025 the Ministry of Health recently launched a campaign and website (called Vaping Facts) to inform smokers of the facts about ENDS and to encourage them to make the switch. The website also clarifies certain myths about vaping and informs that switching can limit exposure to toxic substances, reduce risks of heart and lung ailments (including cancer), and has no health impacts for by-standers.
Where do Things Stand in India?
In our country, the Government permits sale of cigarettes unchecked through local shops that can be found every 100 meters with a thriving business, selling to kids and minors with no identity checks and balances and yet, wants to ban the sale of e-cigarettes which will move smokers away from combustible carcinogens and can become an alternative.
Unfortunately, any kind of ban has massive negative unintended consequences apart from being ineffective. Bans push the market underground and increases the likelihood of illegal procurement and possession, lead to a loss in state revenue, loss in employment and livelihoods, increases corruption, and ultimately harms the very people it seeks to protect as the cost of enforcement exceeds the benefits of such a ban.
Healthcare is complex. So are the solutions to address its many challenges. We need scientific solutions to accelerate the efforts towards addressing the tobacco burden. When you are treating patients addicted to smoking, a “quit or die” approach will do more harm than good. We need to look into the effectiveness of alternatives that reduce the risk. We are flogging a dead horse if we expect tobacco addicts to quit without giving them an option they can rely on. We must tap the immense potential in the use of viable alternatives to reduce the tobacco burden and improve public health indicators in the country.
(Dr Sameer Kaul is Senior Consultant Oncology and Robotics, Apollo Cancer Institute, New Delhi.)