Technology has permeated every nook and corner of our lives. It is even changing the way people smoke, whether for the better or worse is yet to be determined. Electronic nicotine delivery systems (ENDS), the most common prototype of which are e-cigarettes, are the new-age formula for people trying to quit smoking. However, they present a simultaneous promise and threat in the world of tobacco control. Although they are projected as ‘tobacco cessation’ products by various sellers, including tobacco giants themselves, the lack of concrete evidence in support of this claim coupled with the absence of any regulatory approval for their use make them a serious public health threat. This is especially the case when one considers the increasing import of e-cigarettes into the country. Market research also projects the compound annual growth rate of the Indian e-cigarette industry at 63.38 per cent in the period 2013-2018 (Research and Markets Report on E-cigarette Market in India 2014-2018).
Danger without warning
As e-cigarettes contain nicotine and not tobacco, they do not fall within the ambit of the Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003 (COTPA), which mandates stringent health warnings on the packaging and advertisements of tobacco products. Most e-commerce websites sell e-cigarettes as therapeutic products which enable people to quit smoking. We went through 26 prominent and easily accessible e-commerce websites that sell e-cigarettes to study whether these products were sold with appropriate health warnings. The results of the survey are not heartening.
Of the websites, 50 per cent have no health warnings on the consumption of e-cigarettes despite the fact that these products contain nicotine. Eight additional websites, which comprise 30 per cent of the dataset, display warnings in an inaccessible manner. These websites carry health warnings stating the addictive properties of nicotine and other ill effects of e-cigarettes (including the warning that e-cigarettes are not meant for non-smokers) but do not display them as a part of the description of the product. Instead, these warnings are displayed at the bottom of the web page or clubbed with the section on terms and conditions, unlikely to be noticed by a regular buyer. In one case, the health warning was incorrect, stating that “nicotine does not pose major health issues even at a higher volume of consumption.” Other dangers posed by e-cigarettes, which do not feature in the health warnings, are the possibilities of the product exploding (incidents have been reported globally) and accidental consumption of the liquid inside the e-cigarette, which leads to death.
The current unregulated sale of e-cigarettes is dangerous for a country like India where the number of smokers is on the decline (WHO Global Report, 2015) as it increases the possibility of e-cigarettes becoming a gateway for smoking by inducing nicotine addiction and perpetuating smoking by making it more attractive, thereby encouraging persons to become users of tobacco as well as e-cigarettes. In the absence of clearer evidence on the effect of e-cigarettes on tobacco cessation, it is imperative that their sale be accompanied by accurate health warnings. This is especially relevant in India, where data in the Global Adult Tobacco Survey 2009-2010 suggests that tobacco control laws, particularly the pictorial health warnings and advertisements, mandated under COTPA, have been highly effective in increasing awareness of the health risks of tobacco (smoking as well as non-smoking). More than 70 per cent of persons surveyed noticed health warnings on cigarettes, while approximately a quarter thought of quitting on seeing this warning. The effectiveness of such warnings in ultimately reducing tobacco consumption has also been confirmed by the WHO.
The way forward
The Indian government has been slow to respond. Since the first declaration of its intention to ban e-cigarettes containing nicotine in 2014, only Maharashtra, Kerala, Karnataka and Punjab have implemented the ban. The State governments are adopting different routes: Punjab has classified nicotine as a poison, while Maharashtra treats it as an unapproved drug. Lack of a uniform approach in dealing with this public health problem will not only jeopardise the health of the people, but will also enable the sellers of such products slip through the holes. The unaccountable delay in taking an action in this regard is a reflection of the apathy of the governments towards a serious and potential public health problem.
In this light, it is recommended that first, the Indian government impose appropriate restrictions on the sale and advertisement, online and otherwise, of e-cigarettes, including proper health warnings, in order to plug the existing regulatory vacuum. This should be done with immediate effect, and simultaneously the government should also commission independent scientific research on the benefits and risks posed by these products in the Indian context. On the basis of this research, it may then make an informed decision regarding their regulation as tobacco imitation products or as therapeutic products.
