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The challenges of tobacco regulation in India – ET HealthWorld

by Dr. Kiran Melkote

Tobacco use is a widespread problem in India with major healthcare implications translating into a significant economic burden both from the cost of treatment and manhours lost. Yet it boggles the mind why this state of affairs has been allowed to continue for so long.

There is no doubt tobacco use is dangerous and addictive – it keeps millions dependent across the world. Users are not oblivious to this fact, and many recognise they need help with quitting. The reasons for initiation are many, but dependence is the end result and dependents deserve our help and support.

Successive health ministers have tried to shift our attention from the main problem, which was and continues to be widespread tobacco use among Indian adults. Trying to control associated behaviour through indoor smoking bans and no-smoking zones is akin to telling people that it is okay to consume tobacco in certain situations. I can think of no situation where tobacco use is not harmful and this message gets obscured by focusing on allied behaviour. When the government acknowledges the harmful nature of tobacco, allowing any tobacco use is tantamount to abetting suicide.

But instead, in India we get a government, ostensibly responsible for safeguarding our lives, directly being involved in the manufacture and sale of tobacco through its significant stake in the tobacco monopoly. There is an inherent conflict of interest here: manufacturing a deadly tobacco product is opposed to the government’s duty to protect its citizens, and in direct conflict with the goal of tobacco cessation. Any decision taken in the apparent interest of public health will always conflict with its fiduciary duty to the tobacco industry and vice versa.

This dichotomy as the part owner of a deadly product making company as well as the guardian of public health is resolved when we follow the money. Tobacco manufacture and sale provides dual income to our government via sales and taxes. Therefore, instead of aiming to eliminate tobacco use, the government goes after ancillary aspects like smoking in public, advertisements, pictorial warnings and punitive taxation. Tobacco taxation in India is deeply unethical. The government acts as the enabler of tobacco dependence by manufacturing cigarettes, while at the same time leveraging this dependence to fill its coffers using high ‘sin taxes’ on tobacco products.

Like any other toxic substance, tobacco harm also exists on a spectrum or a continuum of risk. Dose and duration are the key determinants of the degree of harm. Therefore, some tobacco products are logically more harmful than others. Despite this knowledge, we continue to follow an arbitrary scheme of taxation, with widely used and highly harmful products like beedis taxed at a very low rate.

When vaping and electronic systems came along as a low-risk alternative for tobacco users, our government chose to ban them. This makes one wonder if it was to safeguard its industry interests against a potential competitor. This conflict of interest seemed obvious to everyone except the World Health Organisation (WHO) which presented an award to our country for the vape ban. This was like giving an award to a drug dealer for eliminating his rivals and establishing a monopoly!

The traditional tobacco control movement as well as the WHO have lost sight of the big picture. Instead of broadening their focus to encompass improvements in public health, they remain fixated on narrow strategies that have questionable success – imagine if you are tobacco dependent, will pictorial warnings or ad bans affect your dependence in a major way? Sure, they may help prevent people from starting in the first place, but what about those who are already dependent? Touting these steps as effective for tobacco cessation (when in fact these aim to reduce tobacco uptake) shows a lack of understanding and empathy.

The WHO and our government believe that tobacco cessation is easy as deciding to quit and ignore or trivialise the science that points to dependence. If at times they do acknowledge it, their prescription for tobacco cessation persists in undercutting the means to tackle dependence. Bans on low-risk nicotine substitution products like vaping only underscore this point.

Vaping, snus (a Swedish smokeless product like khaini but significantly less harmful) and other low-risk variants are the future of tobacco use. Just like we moved away from wood burning stoves to gas and electric hobs to reduce associated harms, these avenues address the ills of tobacco directly. These nicotine delivery methods that are proven to be less harmful compared to traditional tobacco offer an incredible opportunity to improve public health and lower the burden imposed by tobacco use. However, the WHO and many countries (including India) have refused to even consider these harm reduction alternatives, while continuing to conflate tobacco and nicotine and use both terms interchangeably.

Imagine if such an approach was applied to other new technologies like electric cars. We would live in a world where fossil fuel cars are promoted over electric vehicles (which would be taxed more, described as unsafe, and banned) to protect the oil industry and citing the need for oil taxes to fight climate change – that is the world that tobacco control and WHO currently inhabit with their flawed strategies for reducing tobacco harms.

The way forward may be pragmatism, but not fake pragmatism where the government bans a safer alternative citing their inability to ban cigarettes first and their intention to be ‘pragmatic’ about it. If tobacco control in our country really is about public health, then the hypocrisy must end. Recognise the role of harm reduction for tobacco. Nicotine is not the villain we think.

Dr Kiran Melkote is an orthopaedic surgeon based in New Delhi and member of Association for Harm Reduction Education & Research (AHRER), a body of medical professionals focused on risk-reduction interventions in public health.

(DISCLAIMER: The views expressed are solely of the author and ETHealthworld.com does not necessarily subscribe to it. ETHealthworld.com shall not be responsible for any damage caused to any person/organisation directly or indirectly.)

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