Up to 190,000 Indians used now-banned electronic cigarettes, as harmful to the human body as other tobacco products – including cigarettes, beedis and chewing tobacco – which will continue to be used by 267 million Indians.

In other words, 1,405 times more Indians use other tobacco products than they do – or did – e-cigarettes, according to a FactChecker.in analysis of various government and international health data.

The damage inflicted by other tobacco products appears to be more than e-cigarettes, according to a leading Indian expert and global evidence. Another Indian expert said the lack of a ban on tobacco cannot be the justification for introducing a new addiction, even though it may be less harmful.

While e-cigarettes do not burn tobacco, they contain more nicotine than cigarettes, and nicotine adversely affects health, as we explain later. E-cigarette vapours can contain substances that cause heart, lung disease and cancer, and users are also more likely to try out cigarettes later, the evidence shows.

A public debate over the ban focussed on why other tobacco products faced no similar action.

The government of India banned production, manufacture, import, export, transport, sale, distribution, storage and advertisement of electronic nicotine delivery systems, as e-cigarettes are formally known, on September 18, making it a “cognizable offence”, or one in which the police can make an arrest without a warrant.

E-cigarettes or electronic nicotine delivery systems are battery-operated devices used to smoke or vape. A solution is heated to create an aerosol containing flavour-making agents with “varying concentration of nicotine”, an addictive component found in tobacco products.

Another addiction?

“It is very obvious that cigarettes and smoke-less [tobacco] are more harmful [than e-cigarettes],” said Ravi Mehrotra, chief executive officer of the Indian Council Of Medical Research’s India Cancer Research Consortium, who supported the e-cigarette ban.

“More than 65% of our population is less than 35 years of age, so why do you want to bring in more harmful substances when we already have others?” said Mehrotra. “People are also taking up smoking [regular cigarettes] to leave addiction of e-cigarettes, which is harmful. So better to avoid it, rather than getting into that which is totally unproven and has no positive health effects.”

The common substance to e-cigarettes and cigarettes is nicotine.

“Nicotine is the most addictive substance in the world,” said Mehrotra. “Pure nicotine is a poison and it is not cleared by the drug controller of India. It may not be causing cancer but may cause pulmonary and cardiovascular disorders.”

The government told the Lok Sabha on June 21, citing a World Health Organization study, “Nicotine can have adverse effects on the development of the foetus during pregnancy and may contribute to cardiovascular disease. Nicotine itself is not a carcinogen, it may function as a tumour promoter and seems to be involved in the biology of malignant disease, as well as of neurodegeneration.”

E-cigarettes are also harmful to non-users, with adverse health impacts on those exposed to second-hand vapours, according to a white paper released by the Indian Council Of Medical Research in May. Consumers of e-cigarettes are “more likely to use regular cigarettes later”, the report said, citing previous studies.

A cartridge of e-cigarette holds about as much nicotine as a pack of 20 regular cigarettes and can act as a source for nicotine addiction, according to the white paper. It also states that e-cigarettes increase the chances to try-out regular tobacco products, increasing the desire to smoke cigarettes.

More than 460 e-cigarette brands available in India mix the flavours and effects of traditional tobacco products – such as cigarettes, pipes, cigars – and come shaped like flash drives, flashlights or pens and are targeted at young people.

Addressing the question “is e-cigarette use less harmful than smoking regular cigarettes?”, the American Cancer Society on its website states that the use of e-cigarette is “likely to be significantly less harmful for adults than smoking regular cigarettes”, based on research.

“E-cigarettes do not contain or burn tobacco – a process that produces an estimated 7,000 chemicals, including at least 70 chemicals that cause cancer – but the health effects of long-term use are not known,” said the society. “Although the term vapour may sound harmless, the aerosol that comes out of an e-cigarette is not water vapour and can be harmful. E-cigarette vapour can contain substances that are addictive and can cause lung disease, heart disease, and cancer.”

No degrees of harm

The damage inflicted by e-cigarettes is as much as cigarettes or consuming any other tobacco products, said Pankaj Chaturvedi, professor, department of surgical oncology, head and neck services, at the Tata Memorial Hospital, Mumbai.

“It is equivalent to saying that jumping from the 10th floor is safer than jumping from the 13th floor,” he said. “Less harm does not mean harmless. E-cigarettes contain nicotine, which is a highly toxic chemical that can adversely affect any organ of the body. A dosage of 30-50 mg of nicotine can kill an adult human. Nicotine in pure form may also cause cancer.”

“Nearly 80% of those who start e-cigarettes to quit cigarettes can’t quit, as it deprives a quitter of nicotine-free life despite quitting cigarettes successfully,” said Chaturvedi. “It can only help a small fraction of smokers to quit. E-cigarettes lure those smokers who have already quit cigarettes to re-initiate smoking [e-cigarette] under the false notion that it is harmless. Since e-cigarettes have a small consumer base, a ban will be highly effective. The lack of a ban on tobacco can not be the justification for introducing a new addiction even though it may be less harmful.”

E-cigarettes relatively unknown

The use or consumption of e-cigarettes in India is marginal compared to other tobacco products.

No more than 3% of Indian adult, 15 years and above, were aware of e-cigarettes, and there were 0.02% – about 190,000 – estimated e-cigarette users, according to the second round of Global Adult Tobacco Survey, 2016-’17, which the government quoted in a reply to the Lok Sabha on June 21.

Tobacco use, aged 15 years and above, reduced by six percentage points over seven years, from 34.6% in 2009-’10 to 28.6% in 2016-’17, the government told the Rajya Sabha in an earlier reply on February 5. Tobacco users reduced by 8.1 million, as per Global Adult Tobacco Survey, 2016-’17.

“The decision to prohibit e-cigarettes will help protect population (sic), especially the youth and children, from the risk of addiction through e-cigarettes,” said the government’s September 18, 2019, press release. “Enforcement of the ordinance will complement government’s efforts for tobacco control and will help in the reduction of tobacco use and reduction in associated economic and disease burden.”

About 30 countries, including Mauritius, Australia, Singapore, North Korea, Sri Lanka, Thailand, Brazil, Mexico, Uruguay, Bahrain, Iran, Saudi Arabia and the UAE, have banned e-cigarettes, according to the 2017 WHO Report on Global Tobacco Epidemic.

This article first appeared on FactChecker.in, a publication of the data-driven and public-interest journalism non-profit IndiaSpend.