By Clive Bates, Director, Counterfactual Consulting, London
After China, India has the world’s second-highest number of smokers – about 90 million. We know that long-term smoking is a major cause of cancer, heart disease, and debilitating respiratory diseases. Smoking kills more than obesity, alcohol, road accidents, drug misuse and HIV combined. As a result of smoking, millions of people die prematurely in agony or live in misery as they age. What should be done?
As it happens, there is good news and bad news. The good news is there has been a recent revolution in technology that could bring this epidemic of pain and sorrow to a rapid close. The bad news is that, like many revolutionary innovations, it is facing strong resistance.
First, let’s describe the problem in more detail. It is now common knowledge that people “smoke for the nicotine but die from the tar”, a phrase first coined in 1976 by the British scientist Michael Russell. This means that many people like to use the drug nicotine, a mild stimulant with calming effects. Nicotine provides a physiological reward and can form dependence, but nicotine is not the cause of smoking-related disease and death. With smoking, cured tobacco leaves burn at 900oC at the tip of a cigarette. The burning creates the energy to form an inhalable smoke containing nicotine, but it also forms thousands of toxic by-products of combustion. This is the lethal tar that Professor Russell referred to.
The good news is that there is now a full range of products that can provide nicotine without burning tobacco and therefore without the products of combustion or the tar that does the damage. This is because advances in technology have led to batteries powerful enough to create an aerosol by heating a liquid containing pharmaceutical grade nicotine rather than burning tobacco leaves. As a result, these technologies avoid combustion, as well as the products of combustion, which minimizes disease risk to a large extent. No one should describe them as “safe”, but they are much safer than smoking beyond any reasonable doubt. This is the thinking behind vaping products, often known as e-cigarettes, and also a new generation of “heat-not-burn” tobacco products.
The 2016 report, Nicotine without smoke: tobacco harm reduction by the eminent Royal College of Physicians of London, concluded that “Although it is not possible to precisely quantify the long-term health risks associated with e-cigarettes, the available data suggests that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure”.
This range of technologies provides the basis for replacing cigarette smoking as the dominant way of using nicotine worldwide. We already have enough evidence that smokers will switch to these products from randomised controlled trials, observational studies, market data and population data.
In England, the public health authorities advertise through Television and magazines to encourage smokers who can’t quit smoking, or just do not want to quit using Nicotine and switch to vaping. This has worked. Better still, millions of people have taken a big step forward to protect their own health on their own initiative and, at their own expense.
The flip side is that in 2019, the Indian government completely banned these smoke-free vaping and heated tobacco products. Unlike most countries, smokers in India no longer have the option of switching to a lawfully supplied low-risk alternative to cigarettes. This is just a part of the worldwide prohibitionist reaction to these innovations that originates in the United States and has been promoted globally by billionaire philanthropists.
Like all prohibitions, the move was driven by two fundamental misunderstandings. The first is that when something is banned, it will somehow disappear. The war on drugs counters this assumption. A prohibition just changes how the product is supplied, who supplies it and at what price – in other words, the black market takes over. The second misunderstanding is the belief that when something is banned, its users will stop doing it and do something virtuous instead. On the contrary, these users may continue to smoke, relapse from vaping to smoking, mix their own liquids or buy from the black market.
These are often called “unintended consequences”, though they are entirely predictable. But no one has evaluated its impact on smoking, on vapers, or on black markets. Sadly, the prohibition reflex runs deep in the culture of tobacco control and drug policy, and this movement is now waging a misguided and lethal war against pro-health consumer-driven innovation.
Disclaimer – I have no conflicts of interest with respect to the tobacco, nicotine or pharmaceutical industries.
(With inputs from health)