‘Harm reduction is the future of tobacco regulation’

tobacco regulation and harm reduction
Tobacco regulation should help people who want to stop the habit of using products that are harmful to health and allow them to embrace less harmful products.

Tobacco regulation and harm reduction: I was a member of the Rajya Sabha when the Prohibition of Electronic Cigarettes (Production, Manufacture, Import, Export, Transport, Sale, Distribution, Storage, and Advertisement) Bill, 2019 was introduced by the then health minister Dr Harsh Vardhan. It was brought in to replace an Ordinance promulgated in September 2019. The basic reason why I spoke against the bill was because I have been a student of risk regulation.

Around the time in 2014 when I was elected to Parliament, I had published a book with Oxford University Press called, India’s risks, which focused on health, environment safety, and climate change. It contained an array of essays on that particular topic approaching it from a scholarly perspective, and with some understanding of how things have changed and how things should change around the world. I have never vaped and probably will never do so. I suddenly became a hero to the vaping community.

Let me delve deep into some of the complexities of this domain. One of the fundamental challenges is the nature of cause and effect in the tobacco consumption domain. You may have a cigarette today, but the actual impact may be felt 30 years later — that too with possible continuous exposure over time. I must say here that I’m an occasional smoker myself and had my first cigarette at the age of 15 — the day my high school exams ended.

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This was around the time a new brand called Charms hit the market. Charms was packaged in a blue jeans kind of a packet and their advertisements featured modern themes. There was a couple on a motorcycle and the slogan was – “give me the highway, give me my girl and give me the taste of toasted tobacco”. You can imagine what this was for a youngster who was 16/17 years old – aspirations of a bike, girlfriend, associated with toasted tobacco packaged in a nice blue jeans packet. It ended up prodding many people to have their first cigarette.

Dr. Harsh Vardhan who piloted the bill brought up the argument that the police had raided a school and found a lot of smoking devices in children’s bags. I said why are you raiding schools. It doesn’t seem the right thing to do. I pointed out that youngsters are going to experiment. If it is not this, they will try something else. I am not sure that you can change them. If you stop him, then they may experiment with worse things. So, there is always a trade-off.

When I talk about trade-offs, they are the central features of this regulatory domain. On the one hand you have farmers who are growing tobacco, you have very poor people who roll beedis for a living. So, there are livelihoods involved, and also the government’s revenues from tobacco and alcohol. You know these are harmful products, but the way the governments have played these is to say, “okay we will increase the price to some extent and hope that people will reduce their consumption”. However, the impact of higher taxes and higher prices fades out over time.

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Sin tax and tobacco regulation

Economic measures don’t have much of an impact because of the other dimension of tobacco which is the addiction aspect of it. People get addicted to nicotine and they want stimulation from it. People will pay higher prices if it comes to that, at least in India. Since we allow loose sale of cigarettes anyone who wants an occasional cigarette can still get it. If you buy a packet which is the western practice, you will actually smoke that entire lot. It is there with you and you will start smoking first thing in the morning until last thing at night. You will end up smoking more.

We are talking about tobacco being consumed in different forms in cigarettes, which is the refined form. There is also chewing tobacco, the health impact of which is tremendous. Unfortunately, the health impact of chewing tobacco has not been well understood because the victims discover this much later in life. There’s another feature associated with this. For the longest time, the notion of regulating tobacco intrusively was not taken up because it was seen as a voluntary risk, something which you had chosen for yourself. That’s why you had all that seductive advertising. But you also had smoking in public spaces, at home which was never seen as something to be disapproved of.

In the West, the tobacco industry ensured that the direct connection between tobacco smoking and cancer and other lung diseases was never easily proved. That was still always a leap of faith that changed over time, but the biggest change in attitude came from the recognition of the impact of second-hand smoke. It was no longer voluntarily subjecting himself or herself to this particular risk, but you’re actually subjecting your neighbour, your family members and everyone else. That’s when societal attitudes started to change. You started to see people saying , “please smoke outside or far away”.

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Growing up, we have been on planes where you could smoke. They would hand out cigarettes on planes in the 1970s on international flights. If you’re in some old aircraft you might still find a little ashtray in your in your arm rest. Anyway, the point being that, all that has changed. The biggest indicator of societal attitude change was witnessed when I was in the US. I started seeing in dating columns, writeups like “only non-smokers should respond”. I don’t know what it’s like with the Tinder generation, but at least in those days you knew that something’s changed. In India, you’ve had bans on advertising, bans on sponsorship.

There is still surrogate advertising of some kind, but that’s not that effective anymore. There are always surrogate ways of doing things but nonetheless the statutory warning, as Mr Prabhu said, didn’t really make much of a difference. In fact, the language was so heavy — “cigarette smoking maybe injurious to health”. Now it’s much more direct – there is a graphic picture covering the brand of cigarette itself and it says smoking will kill you or “smoking kills”. Those are very graphic ways, but again it’s not clear that the effect is very significant.

Anyway, that’s one side of the coin. The other one is this massively impactful regulation that came out in India. I am talking about Anbumani Ramdas’ ban on smoking in public places. There was no one to enforce this, but it has socially been accepted. As a result, you don’t find that many people smoking in public places. This is my anecdotal understanding that it seems to have worked and brought overall tobacco consumption down.

Tobacco regulation should help smokers quit

Another question is, if people do want to reduce tobacco consumption, how do you help them to give up. Harm reduction is the requirement, and this is where I had a disagreement with Dr Harsh Vardhan and the government on their approach to electronic nicotine delivery systems. The science of these new technologies is not fully understood because we don’t yet know their impact. There are some studies from the UK which show that these are less harmful than smoking tobacco.

While smoking, you inhale all kinds of things, burnt paper, carbon monoxide and various other toxic substances, when all you’re after is nicotine. Nicotine patches have been used for quite a while to wean people off direct consumption through smoking. So, the same approach is what is the philosophy behind these newer products which give a nicotine fix without possibly harming as much as smoking tobacco.

There may still be some harm and we don’t know what these are, because even these devices use different kinds of material to get nicotine fix to you. I have forgotten the technical language for that, but nonetheless, the basic thing is that you are using some organic chemicals to create the smoke sensation. We don’t know the impact from their consumption, but on the basis of studies done in the US and the UK, these new technologies should not be banned.

The minister and the health secretary at that time were very insistent that a ban was imperative and urgent. I think some new products were about to enter the Indian market and they wanted to stop these from entering India. The then secretary wrote an op-ed piece where she said that she had seen youngsters using these devices in a park and it upset her. That should hardly be the basis for such a stringent regulation. My proposal there was don’t ban as ban will lead to underground activities. My prediction came true and all kinds of products are available in the market and there is no way to ensure good quality.

My solution was to introduce nicotine patches and other solutions which are offered to people through prescriptions. You know, children just can’t get hold of them. People who want to stop smoking tobacco could move towards the alternatives. But the minister was unmoved and the opposition MPs were divided. There were occasions when the government listened to me as in the case of the surrogacy bill even though the bill had been passed in the Lok Sabha. They set up a select committee and changed the law after accommodating our views. So, occasionally opposition members had some impact, but sadly not in this case.

I continue to write about this. I’m also working on a policy paper on the subject and I’m speaking about this because I do think that it’s never too late to reconsider. The direct and indirect health cost and the economic cost on people and their families are tremendous. So, it’s imperative that tobacco regulation evolves to reduce harm and to provide people with enough information to wean themselves off these addictions. For that, you need alternative methods including ENDS which will allow people to phase out over time and that’s the submission I have here today. I hope that we will move towards a future which is much more rational.

(Rajeev Gowda is the chairman of the research department of Indian National Congress. He is a former member of the Rajya Sabha. This article is an edited version of his speech at a Policy Circle seminar on ‘Future-proofing Tobacco Regulation in India’.)