Tobacco Harm Reduction - A Missed Public Health Opportunity for India

In conversation with Dr. Sree T. Sucharitha, M.D. Professor and Founding-Director – AHRER (Association for Harm Reduction Education and Research)

How can India take its tobacco control measures to the next level?

Tobacco causes about eight million avoidable deaths and is responsible for over 12% of premature deaths globally. In India, tobacco use in various forms, decreases life expectancy by 11 years among women and 12 years in men. Failure to rapidly implement global tobacco control measures is predicted to result in one billion tobacco-related deaths in the 21st century. The WHO Framework Convention on Tobacco Control (FCTC) implements tobacco control policies such as price and tax increases, pictorial warnings, prevention of smoking in public and workplaces, monitoring trends in tobacco use, quit lines, and ban of tobacco advertisement and promotion. These policies have helped in achieving reductions in smoking prevalence of about 1% per year. However, they focus primarily on non-health-related approaches to tobacco control and thus fail to directly address smoking cessation and harm reduction strategies which can enhance improvements in health outcomes. According to the National Health Policy, India has set a target of 30% reduction of tobacco users by 2025, and to achieve this the opportunity is in adopting wide-scale tobacco harm reduction (THR) policies.

How will the adoption of THR policies help India?

As per GATS-2 survey, India has the second-lowest quit rates among surveyed countries despite high awareness. Indian research reports only 2-5% smokers spontaneously quit smoking in India. Adoption of THR into the National Tobacco Policy to support those who are unable to, or do not wish to quit is a clear challenge and obstacle. One must remember that the oral cancer malignancy is 7.6% in India (1.2% in China) owing to a wide variety of chewable tobacco (pan, khaini, ghutka) available for low-income groups. THR is the future since for long-term users of tobacco, engaging them in a ‘continuum of care’ patient-centric mode, is a challenge in a health system that offers partial, piece-meal services but not ‘one-stop’ centres with a package of services to ‘opt-in’ for, either free-of-cost or at discounted prices. Developing a THR product landscape aided by technology, at scales and cost the low-income group consumers can afford, serves to overcome the above challenges by leveraging ‘social marketing’ (used earlier for promoting iodised salt and oral contraceptives, condoms), which can help flip these obstacles with the backing of strong political will in adopting THR policies.

How can we encourage more smokers to quit smoking?

It is long recognised that a combination of behavioural support and treatment approaches are most effective to help smokers to quit. Despite these interventions, 80% continue to smoke one year later. Most physicians in my research revealed misperceptions about nicotine risks and these are critical gaps in providing ‘client-centred’ care. Brief research communications on nicotine literacy, availability of reduced-risk nicotine alternatives and increasing awareness of THR are essential in correcting misinformation among policy makers, physicians and the general public.

How can the government leverage THR policies to regulate access to nicotine products and what is the need?

By 2030, the proportion of tobacco-related deaths will have risen to 70% in low-income countries and among them, the majority will be in vulnerable populations such as migrants and LGBTQ+ communities as tobacco use tends to be high in these groups due to prevailing disparities in social-determinants of health like poverty, poor health-seeking behaviours and misinformation about smokeless tobacco products. THR can be leveraged to address the needs of adult tobacco users by regulating access to reduced-risk alternative nicotine products by ensuring age-appropriate access to them and increasing socio-behavioural research funding to understand the consumers’ feelings towards these products versus medical products like NRTs (gums and patches). Research from developed countries confirms that consumers prefer to make safer choices when provided with reduced-risk alternatives and the right information by credible experts.

What are your recommendations for building a progressive THR framework for the Indian diaspora?

Studies from developed countries show decline in smoking rates after the introduction of safer nicotine alternatives, as in Sweden, Norway, Japan, UK, etc., THR-elements of which can be adopted to suit our national tobacco-health needs.

Policymakers can initiate multi-stakeholder consultations with consumers, public-health analysts, and researchers to develop a progressive and evolving regulatory framework, and include THR in the medical curriculum for under and postgraduate training, and form a panel to address regulatory issues and frame guidelines.

Research into the THR product landscape and regulation (exposure reduction, risk reduction, etc.) needs to be funded, and there should be a special focus on youth, women, sexual and gender minorities, and migrant communities. Further, we need public education campaigns to counter nicotine risks misinformation.

Most importantly, articulating THR in national policies reflects a new forward-thinking which will save lives, and it is needed most urgently.

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