December 5, 2019, is a date to remember. The Prohibition of Electronic Cigarettes Act, 2019 was notified this day. After the Lok Sabha passed the bill on November 27, the Rajya Sabha considered it on December 2. As health secretary, I was watching the proceedings of Rajya Sabha on TV in my office. The health minister made a speech that went beyond the official brief. With a personal commitment, he made an effective case for the ban. The bill got passed by a voice vote, cutting across parties. The spontaneous hurrah that followed was an expression of the fulfilment one experiences sometimes in one’s career as a civil servant. Faced with a powerful lobby, industry-supported doctors, media pressure and legal battles, the process to ban a harmful product was much more challenging than I had expected.
One wintry night, I saw a group of young kids barely 12-13 years of age smoking cigarettes and weed in a neighbourhood park. I was possessed by the thought: What if they were my grandchildren? It was December 2013 and I was the additional secretary in the Ministry of Women and Child Development. I realised that children are seen as an emerging market. I realised that the Juvenile Justice (JJ) Act was being amended and we could use the opportunity to make a legal proviso towards this menace. The role played by a dedicated oncology surgeon from the Tata Memorial Hospital, who would relentlessly take up the cause with stakeholders, needs acknowledgement. The pain of his patients only strengthened his resolve. After due diligence by the concerned Joint Secretary and the support of the minister, the proviso in the amended JJ Act 2015 made the sale of tobacco to minors a criminal offence punishable by seven years of rigorous imprisonment. We are one of the few countries to have a powerful deterrent that firewalls our children.
When I was posted in the health ministry, I could contribute to the cause further. India had embarked on a multi-pronged approach to reduce tobacco consumption. In addition to ratifying international treaties on global tobacco control (FCTC), India had a legislative framework, price and tax measures to reduce demand, regulation of contents of tobacco products and disclosures, deterrent packaging and labelling norms, the prohibition of advertising, promotion and sponsorship, several awareness measures, and also a free helpline/Quitline.
Considering that 26.68 crore Indians use tobacco, its reduction is a mammoth job. However, we achieved a 17 per cent relative decrease in tobacco consumption between 2010 and 2016 — the highest globally in such a short span. Consumption among children showed a 33 per cent decline.
Just as we were able to take measures to protect our young from tobacco, a new threat emanated from the western world. Promoted as a less harmful alternative to cigarettes, this was the electronic nicotine delivery system (ENDS) which contained a toxic and addictive chemical (nicotine) available in nearly 7,000 flavours. India, with its young population, was viewed as a lucrative market. A committee of experts coordinated by a dedicated doctor was constituted to examine the matter. This, and later a task force of the ICMR, suggested a ban. But the lack of an appropriate legal provision turned out to be our Achilles’ heel.
In October 2018, I represented India as president of the eighth session of the WHO’s FCTC Conference of Parties (COP8). On ENDS, there was some confusion and countries were looking for evidence-based research. Interestingly, the global evidence against ENDS had also started emerging.
Research by an assistant secretary under-training brought clarity on the subject. A study published in 2018 on students in the US, found e-cigarette to be a gateway product to conventional smoking and tobacco use, severely undermining the country’s tobacco control efforts. The US Surgeon General in December 2018 issued an advisory that ENDS use among school students had increased by 900 per cent during 2011-2015. The WHO, in 2019, stated that scientific evidence on e-cigarettes as cessation aids is inconclusive. ((Lung injuries caused by COVID-19 and its manifestations are similar to those caused by e-cigarettes, new studies published in SAGE Open Medical Case Reports and Lancet have revealed.)
The new Indian government in May 2019, by including the issue in the first 100 days’ agenda, exhibited political will. Since ENDS was never approved in India, an advisory was issued to states to stop the illegal sale. Sixteen states prohibited e-cigarettes. The action by state governments and the Centre’s advisories were challenged and stayed by courts. By June 2019, news emerged about deaths and mysterious lung injuries from the US. At this point, one of the leading ENDS manufacturers rolled out a plan for their launch in India by end-2019.
Legal opinion suggested an ordinance to stop the march of ENDS in India. The GoM under the finance minister recommended a ban in one sitting. The ordinance was approved on September 18, 2019. As expected, it was challenged in court. However, no stay was given.
The launch of e-cigarettes in India had been successfully stalled. As I sat watching the Parliament proceedings, apart from feeling a sense of fulfilment that timely action had saved our children from addiction, I also felt humbled at how at each stage, political will at the highest level, and support and collaboration helped find solutions.
This article first appeared in the print edition on December 7, 2020 under the title ‘Stubbing out a crisis’. The writer is former Secretary, Health & Family Welfare
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