In a directive issued on August 28 to all States and Union Territories, the Union Ministry of Health and Family Welfare (MoHFW) has stopped the manufacture, sale, distribution, import, trade and advertisement of Electronic Nicotine Delivery Systems (ENDS) such as e-cigarettes, vaping devices, e-sheesha, e-nicotine-flavoured hookah and heat-not-burn devices, citing the risk posed to children, adolescents and women in the reproductive age. It adds that ENDS has already been banned in 30 countries.
Such devices are often misunderstood as Nicotine Replacement Therapy (NRT) for those who aspire to quit tobacco use, and the Ministry’s notification puts an end to the belief that they help in tobacco cessation and are safer than cigarettes or other forms of tobacco-consumption as most do not contain tobacco — the source of nicotine and which is one of the most addictive substances.
In most ENDS, instead of tobacco, nicotine is used in a chemical form. Thus, users of these devices believe that they are not smoking tobacco, but in reality, they continue to have the addictive chemical.
“People believe that the cancer-causing element is absent in the devices and are simply getting the pleasure of smoking. But several studies have found that use of ENDS leads to initiation of smoking,” says oncosurgeon Dr. Pankaj Chaturvedi of Tata Memorial Hospital, Mumbai, adding that the dependence on smoking rises with such devices.
He was a part of an MoHFW roundtable discussion on ENDS in 2014. There, doctors, specialists, scientists and officers from the health and drug departments concluded that available scientific evidence indicated that ENDS and similar technologies encouraged tobacco use, were hazardous for active as well as passive users, and had an adverse impact on public health.
A cigarette contains four to six milligrams of nicotine whereas most cartridges used in ENDS contain an equivalent of 10 mg of nicotine, but in liquid form. While the cost of a cigarette starts from ₹7, a cartridge costs at least ₹200. Experts say that when it begins to pinch the pocket, most ENDS users go back to cigarettes. Nicotine gums and patches formulated under a valid drug manufacturing licence (with 2 mg and 4 mg of nicotine content) are the only approved forms of NRT currently.
“There is no data or literature that supports any positive health outcomes from ENDS. Worse, many children are falling prey to its use as they are under the false belief that the absence of tobacco makes it safe. Many doctors wrongly advise e-cigarette use to control their patients’ smoking habits too,” says Dr. Jagannath P., a former tobacco control consultant for the Karnataka government. Dr. Jagannath, who has also worked on a World Health Organization-funded project on the National Tobacco Control Programme, says that till date, no health agency has declared it safe for use.
An article in the Indian Journal of Medical and Paediatric Oncology , in 2015, said that the biological effects of nicotine are widespread and extend to all systems of the body including cardiovascular, respiratory, renal and reproductive systems. It said: “Nicotine has also been found to be carcinogenic in several studies.”
The Health Ministry’s notification highlights that nicotine can have adverse effects on the development of the foetus, may contribute to cardiovascular diseases and could function as a “tumour promoter”.
“Foetal and adolescent nicotine exposure may have long-term consequences for brain development, potentially leading to learning and anxiety disorders,” the notification warns.
Dr. Chaturvedi says that most ENDS available in India are of Chinese make and non-branded. “However, well-known companies like ITC and Philip Morris International (PMI) have ENDS in the form of an e-cigarette called EON and a heat-not-burn device called iQOS, respectively. With the new advisory, these devices cannot be marketed or sold any more,” he says.
PMI calls iQOS its breakthrough — it “heats the tobacco just enough to release a flavourful nicotine-containing vapour but without burning the tobacco” — and contends that “around 5.6 million consumers had already chosen to switch from cigarettes to this product”. A launch in India is now unlikely. When asked about the Ministry’s notice on ENDS, a PMI spokesperson said, “The advisory, if implemented, will deprive over 100 million smokers in India access to, and information about, potentially less risky alternatives to cigarettes.”
“Smoke-free products are widely regarded as being less harmful than cigarettes and tens of millions of smokers worldwide have already made the switch,” he says. “We think that over 100 million smokers in India deserve access to these better alternatives, too.”