Smoking Cessation: The Role Of Policymakers And Tobacco Control Measures

Smoking cessation is the most effective strategy for smokers to reduce their risk of harm and disease. Here is an in-depth overview of smoking cessation and tobacco control measures, read on.

The government of India 2019 introduced the Prohibition of Electronic Cigarettes Act which banned the production, manufacture, import, export, transport, sale, distribution, storage and advertisement of E-Cigarettes, Electronic Nicotine Delivery Systems, Heat Not Burn Products, e-Hookah and the like devices, by whatever name called and whatever shape, size or format may have, but does not include any product licensed under the Drugs and Cosmetics Act, 1940.

Cigarette smoking is one of the leading preventable causes of death and illness in the world. Decades of epidemiological data clearly show that smoking causes several serious diseases (including cardiovascular diseases, lung cancer and chronic obstructive pulmonary disease (COPD)) and nearly six million deaths annually are attributed to tobacco smoke.

India has one of the world’s largest adult smoking populations where the tobacco marketplace accounts for 55-75% of manufactured combustible cigarettes sold as single sticks. Prices of tobacco products in India vary widely. 

Smoking cessation is the most effective strategy for smokers to reduce their risk of harm and disease, and therefore, for many decades, the primary strategies for reducing the harm associated with cigarette smoking have been focused on preventing smoking initiation and promoting smoking cessation. 

To accelerate the decline in smoking prevalence and smoking-related population harm, Tobacco Harm Reduction is increasingly recognized as a valuable and promising approach to complement existing tobacco control measures. 

Tobacco Harm Reduction is based on switching adult smokers to markedly less harmful tobacco and nicotine-containing products, which have the potential to reduce the adverse health effects of smoking. It is widely recognized that the adverse health effects caused by smoking are not triggered by nicotine, but primarily by the toxic substances generated during tobacco combustion (burning).

The heat released by the combustion process breaks down tobacco leaf components generating smoke and ash. Cigarette smoke contains more than 6,000 chemicals, 5 some of which have been classified by public health authorities as likely causes of smoking-related diseases, such as lung cancer, heart disease, and emphysema. 

Nicotine itself at the dosage people seek has relatively small risks. It is the way it is obtained, primarily by the inhalation of smoke but also from unnecessarily toxic mixtures in some other forms of tobacco products, that causes harm. The problem is the delivery system.

Smoking is both an addiction to nicotine and a conditioned habit triggered by various environmental cues. The Tobacco Harm Reduction approach is based on the acknowledgement that innovative products will benefit public health if they meet two conditions: first, they must significantly reduce the risk of smoking-related diseases compared with cigarettes; and, second, they must be accepted by adult smokers to encourage them to switch to such reduced-risk alternatives.

Science and technology today offer new methods for people to quit, combined with Tobacco Harm Reduction (THR) and better clinical tools are the only ways to bring death and disease rates down within 15-20 years. 

Using Heated Tobacco Products (HTPs) or Heat Not Burned Devices (HNBD) for Smoking Cessation

Heated Tobacco Products (“HTPs”) are not electronic cigarettes. They comprise tobacco products (which contain specially processed real tobacco, wrapped in a paper tube, hereinafter referred to as “Tobacco Sticks”) and tobacco heating components/ accessories. 

The heating components/ accessories heat the Tobacco Sticks. Given that HTPs contain tobacco and not liquid nicotine, they are not electronic cigarettes. 

Therefore, “Heat Not Burn Products” should be removed from the definition of “electronic cigarettes” in Section 3(d) of the ENDS Act via an amendment of the ENDS Act or any other appropriate order, and it should be further clarified that tobacco heating components/ accessories are not “like devices” banned by the ENDS Act. 

The ‘Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003’ (“COTPA”), by way of its description, provides scope to regulate other tobacco products and sets out a list of “tobacco products” under a Schedule thereunder. 

Therefore, Tobacco Sticks should be appropriately regulated as tobacco products by adding them to the Schedule of COTPA. Further, since the tobacco heating components/ accessories of HTPs are an integral part of the product, they should also be appropriately regulated.

Research and real-world evidence indicate that HTPs can accelerate declines in smoking and benefit public health. 

Public Health England (PHE) released a report on the evidence behind cigarette alternatives in 2018, the fourth such review on e-cigarettes and the first time it included heated tobacco products. PHE considered eight independent studies on HTPs in its review. 

Amongst the report’s findings on heated tobacco products are a likely reduction in users’ exposure to harmful chemicals compared to cigarettes, and that “The available evidence suggests that heated tobacco products may be considerably less harmful than tobacco cigarettes and more harmful than [e-cigarettes.”

The Superior Health Council of Belgium issued a scientific advisory report on New Tobacco Products: Heated Tobacco Products, in which it provided a risk assessment for heated tobacco products for smokers and non-smokers and guidance to public health policymakers. 

The Council concluded: "In clinical studies, following a switch from conventional cigarettes to heated tobacco products significant decreases in biomarker levels of exposure to harmful and potentially harmful constituents have been observed, although they are not considered to be completely safe. Favourable changes have also been noted in several biomarkers with biological impact, suggesting that there is potential for a decreased risk of disease if smokers switch from conventional cigarettes to heated tobacco products."

The potential of HTPs to accelerate the end of smoking is best evidenced by the case of Japan, where smoking prevalence was reduced by 1% between 2013 and 2016. However, between 2016 and 2019, the Japanese smoking rate reduced by a further 5.2%, as almost three in every ten Japanese smokers stopped smoking cigarettes. This coincided with the national roll-out of HTPs. 

In 2013, Japan had a higher smoking rate than Australia, England, and NZ. Australia had the lowest rate by a clear margin (1.8% lower than New Zealand, 2.6% lower than England, and 3.5% lower than Japan). 

By 2019, Japan’s smoking rate was the lowest, and Australia, the only one of the four to prohibit the sale of HTPs (and, until recently, e-cigarettes) had the highest, despite being the first to implement plain packaging and pursuing a policy of steep annual tax increases.

India is the most populated nation in the world and is a prime location for applying tobacco harm reduction strategies. However, many reduced-risk tobacco products, are banned in the country. By preventing access to alternative delivery systems, the government has eliminated the chance of effective tobacco harm reduction in a country that needs to use all available means to decrease its smoking and tobacco use rates.

In advanced industrialized countries, tobacco control begins and is sustained by deep and effective medical engagement and leadership. If we are serious about tobacco control it is time we show empathy for the needs of smokers and pragmatism from a policy perspective including the measurable benefits of harm reduction. Science must lead the way.

(Disclaimer: The views expressed in the article are those of the author and do not reflect the views of Zee News.)