REGULATORY DOSE

Proposed e-cigarette ban: Users are up in arms, fear they will return to smoking tobacco

Many users of e-cigarettes say the devices have helped them quit tobacco. But the jury is out on the actual safety of these vapourisers.

Even as the Ministry of Health and Family Welfare considers a ban on e-cigarettes in India, vapers across the country are coming together to protest such a move. Vapers are users of electronic cigarettes that are also called e-cigarettes or vapourisers. Vapers in India are worried that a ban will push them back into the habit of smoking cigarettes, which are considered more harmful.

“We are very scared,” said Chirag Gulati, a 27-year-old businessman in Delhi. “We will have to go back to cigarettes.” Chirag had been smoking cigarettes incessantly for five years before he gave them up last year in favour of e-cigarettes.

An e-cigarette is a battery-operated device that contains nicotine but not tobacco. It is often marketed as a smoking cessation device that helps smokers quit tobacco and eventually quit smoking altogether. Along with nicotine, e-cigarettes are filled with propylene glycol – which helps produce vapour – and flavouring agents. They do not contain 6,000-odd carcinogenic compounds found in cigarettes and other tobacco products.

In the United Kingdom, Europe and Canada, the use of e-cigarettes is restricted and regulated, but not banned completely. The countries accept the device as a harm reduction tool that helps people quit smoking tobacco and move on to a habit that is less harmful.

In India, some states like Karnataka, Kerala, Jammu and Kashmir, Punjab and Chandigarh have banned the sale and distribution of e-cigarettes on the premise that they are unsafe, are addictive and can sometimes cause death. If 30 mg of nicotine is consumed in one go, it can be fatal. In fact, the World Health Organisation has maintained that there is little and “low quality” evidence that e-cigarettes actually help smokers quit tobacco and eventually smoking. It also warns that toxicants in e-cigarettes can have harmful effects on a person’s health.

“Nicotine is as harmful as tobacco,” said Arun Kumar Jha, economic advisor to the health ministry who also handles tobacco control. “We have no evidence to show it reduces smoking.”

Jha said that the health ministry is undecided on how to control the sale and distribution of e-cigarettes, as the product does not fall under any statutory law. Currently, there is no clear regulatory framework for e-cigarettes under which the product can be regulated.

In August, the Association of Vapers India – a group of about 300 people who were involved in advocacy related to e-cigarettes – decided to act against the state-level bans that have been passed but not properly enforced yet. The group filed a public interest litigation against the ban of sale and distribution of e-cigarettes in Karnataka. The Karnataka High Court has admitted the petition and will hear the matter at the end of September. The government has to file a reply before the hearing.

Better than cigarettes: Vapers

Rahul Adhlakha, 33, is a Delhi resident who runs a call centre and started vaping two months ago. He had smoked cigarettes for 16 years and had gone up to two packs a day despite suffering chest burns. He had tried quitting several times using nicotine patches and lozenges.

“Once after I quit smoking for two months, I wandered into a shop selling cigarettes while on the phone,” said Adhlakha. “I did not even realise when I reached the shop and when I started smoking again. Only after the call ended did I realise what I had done.”

However, one day, he bought an e-cigarette instead of tobacco cigarettes on whim.

“Since that day, I have not smoked a single cigarette,” he said. “I started vaping with 6 ml of nicotine, but have now reduced the nicotine content to 3 ml in a month’s time.”

Other vapers have similar stories and also report feeling better – higher energy levels, better skin, and better taste and smell.

“Every smoker is sick of smoking and thinks of quitting every single day,” said Abhinav Bhaskar, who runs a shop that sells e-cigarettes.

Some vapers said that they had helped others quit smoking cigarettes and counsel those beginning to use e-cigarettes. Adarsh Kaushal, a vaper from Chandigarh, said that he has encouraged many smokers to try vaping. “For me it is social service and I am doing my bit to save them,” said the 42-year-old web designer. Kaushal smoked for nearly two packs of cigarettes every day for nearly 20 years. He started to smoke when he was 14, and tried quitting at least 20 times.

Another reason vapers like e-cigarettes is because it feels like smoking. Nicotine patches or lozenges do not give the same “hand-to-mouth feel” – the feeling of holding a pipe and inhaling smoke – that vaping does.

Rahul Adhlakha on the extreme right talking about how vaping helped him quit smoking
Rahul Adhlakha on the extreme right talking about how vaping helped him quit smoking

Not devoid of harm

Despite the glowing references from vapers, health experts are divided on e-cigarettes. In 2015, Public Health England, which is the executive agency of the UK Department of Health, concluded that e-cigarettes are 95% safer than smoking and that it has a potential to help smokers quit tobacco products.

Professor Kevin Fenton, director of health and wellbeing at Public Health England, said, “E-cigarettes are not completely risk-free but when compared to smoking, evidence shows they carry just a fraction of the harm. The problem is people increasingly think they are at least as harmful and this may be keeping millions of smokers from quitting. Local ‘stop smoking’ services should look to support e-cigarette users in their journey to quitting completely.”

After examining the latest evidence, the Royal College of Physicians in England, also came to a similar conclusion that e-cigarettes may be beneficial to the their public health. While the report speaks of the need for regulation, it suggested that regulation “should not be allowed significantly to inhibit the development and use of harm-reduction products by smoker”.

The WHO, however, has been vehemently against the product. In its 2016 report, the WHO said that the scientific evidence regarding the effectiveness of e-cigarettes as a smoking cessation is “scant and of low certainly, making it difficult to draw credible inferences.” The WHO raises concerns of the health effects of inhaling nicotine and aerosols. It offers various regulatory options to the member countries including banning it to minors, increases taxes on it, banning advertising and promotion of the product among others.

Countries such as UK, Canada, countries in the European Union more recently New Zealand have placed restrictions on selling the product to young people below the age of 18 years, displaying health warnings on the devices, and restrictions on advertising.

Vaping products should be regulated and have warning labels, the vapers say.
Vaping products should be regulated and have warning labels, the vapers say.

“Don’t ban, regulate”

The petition in the Karnataka High Court clarifies that the association is not contending that e-cigarettes are not harmful, but that they are less harmful compared to tobacco cigarettes. This makes-cigarettes integral to tobacco de-addiction programmes. The petitions asks that there not be an outright ban and that states consider establishing rules, regulations and guidelines for the manufacture, sale and the use of e-cigarettes. The state, the association suggests, can regulate nicotine content and the use of other chemicals. For example, England allows only 2 mg nicotine content in refill packs. It also wants the state to conduct a proper study on the product.

The association is clear that people below the age of 18 should not be allowed to vape.

“The state should open its eyes and do some research before they decide to ban a product,” said Pradeep Herle, a IT professional in Bengaluru, who has been vaping for nearly four years.

Over the past few years, vapers in India have formed several Facebook and Whatsapp groups. So far, they have mostly discussed the kinds of vaping devices available and studies related to vaping. But now, many in these groups have shifted to advocating for vapers. To raise money court procedures before filing the PIL at the Karnataka High Court, the Association of Vapers India conducted a fundraising exercise last month, to which e-cigarette vendors and vapers both contributed.

“Some vapers have made a commitment of contributing every month to the cause,” said Pratik Gupta, director of the association. “About 40% of the contributions are from individual vapers.”

What drives the activism? “The concept of life without tobacco dependence is what keeps us going,” said Imran Saleem, a businessman in Bengaluru, who is active in the association and is helping out with the co-ordination between the lawyers for the petition.

Herle smoked for nearly eight years and has quit smoking completely only about three-and-half-years ago when he started vaping. “An e-cigarette ban hampers my right to a safer life.”

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What hospitals can do to drive entrepreneurship and enhance patient experience

Hospitals can perform better by partnering with entrepreneurs and encouraging a culture of intrapreneurship focused on customer centricity.

At the Emory University Hospital in Atlanta, visitors don’t have to worry about navigating their way across the complex hospital premises. All they need to do is download wayfinding tools from the installed digital signage onto their smartphone and get step by step directions. Other hospitals have digital signage in surgical waiting rooms that share surgery updates with the anxious families waiting outside, or offer general information to visitors in waiting rooms. Many others use digital registration tools to reduce check-in time or have Smart TVs in patient rooms that serve educational and anxiety alleviating content.

Most of these tech enabled solutions have emerged as hospitals look for better ways to enhance patient experience – one of the top criteria in evaluating hospital performance. Patient experience accounts for 25% of a hospital’s Value-Based Purchasing (VBP) score as per the US government’s Centres for Medicare and Mediaid Services (CMS) programme. As a Mckinsey report says, hospitals need to break down a patient’s journey into various aspects, clinical and non-clinical, and seek ways of improving every touch point in the journey. As hospitals also need to focus on delivering quality healthcare, they are increasingly collaborating with entrepreneurs who offer such patient centric solutions or encouraging innovative intrapreneurship within the organization.

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Getting the best from collaborations

Speakers such as Dr Naresh Trehan, Chairman and Managing Director - Medanta Hospitals, and Meena Ganesh, CEO and MD - Portea Medical, who spoke at the panel discussion on “Are we fit for the world of new consumers?”, highlighted the importance of collaborating with entrepreneurs to fill the gaps in the patient experience eco system. As Dr Trehan says, “As healthcare service providers we are too steeped in our own work. So even though we may realize there are gaps in customer experience delivery, we don’t want to get distracted from our core job, which is healthcare delivery. We would rather leave the job of filling those gaps to an outsider who can do it well.”

Meena Ganesh shares a similar view when she says that entrepreneurs offer an outsider’s fresh perspective on the existing gaps in healthcare. They are therefore better equipped to offer disruptive technology solutions that put the customer right at the center. Her own venture, Portea Medical, was born out of a need in the hitherto unaddressed area of patient experience – quality home care.

There are enough examples of hospitals that have gained significantly by partnering with or investing in such ventures. For example, the Children’s Medical Centre in Dallas actively invests in tech startups to offer better care to its patients. One such startup produces sensors smaller than a grain of sand, that can be embedded in pills to alert caregivers if a medication has been taken or not. Another app delivers care givers at customers’ door step for check-ups. Providence St Joseph’s Health, that has medical centres across the U.S., has invested in a range of startups that address different patient needs – from patient feedback and wearable monitoring devices to remote video interpretation and surgical blood loss monitoring. UNC Hospital in North Carolina uses a change management platform developed by a startup in order to improve patient experience at its Emergency and Dermatology departments. The platform essentially comes with a friendly and non-intrusive way to gather patient feedback.

When intrapreneurship can lead to patient centric innovation

Hospitals can also encourage a culture of intrapreneurship within the organization. According to Meena Ganesh, this would mean building a ‘listening organization’ because as she says, listening and being open to new ideas leads to innovation. Santosh Desai, MD& CEO - Future Brands Ltd, who was also part of the panel discussion, feels that most innovations are a result of looking at “large cultural shifts, outside the frame of narrow business”. So hospitals will need to encourage enterprising professionals in the organization to observe behavior trends as part of the ideation process. Also, as Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital, points out, they will need to tell the employees who have the potential to drive innovative initiatives, “Do not fail, but if you fail, we still back you.” Innovative companies such as Google actively follow this practice, allowing employees to pick projects they are passionate about and work on them to deliver fresh solutions.

Realizing the need to encourage new ideas among employees to enhance patient experience, many healthcare enterprises are instituting innovative strategies. Henry Ford System, for example, began a system of rewarding great employee ideas. One internal contest was around clinical applications for wearable technology. The incentive was particularly attractive – a cash prize of $ 10,000 to the winners. Not surprisingly, the employees came up with some very innovative ideas that included: a system to record mobility of acute care patients through wearable trackers, health reminder system for elderly patients and mobile game interface with activity trackers to encourage children towards exercising. The employees admitted later that the exercise was so interesting that they would have participated in it even without a cash prize incentive.

Another example is Penn Medicine in Philadelphia which launched an ‘innovation tournament’ across the organization as part of its efforts to improve patient care. Participants worked with professors from Wharton Business School to prepare for the ideas challenge. More than 1,750 ideas were submitted by 1,400 participants, out of which 10 were selected. The focus was on getting ideas around the front end and some of the submitted ideas included:

  • Check-out management: Exclusive waiting rooms with TV, Internet and other facilities for patients waiting to be discharged so as to reduce space congestion and make their waiting time more comfortable.
  • Space for emotional privacy: An exclusive and friendly space for individuals and families to mourn the loss of dear ones in private.
  • Online patient organizer: A web based app that helps first time patients prepare better for their appointment by providing check lists for documents, medicines, etc to be carried and giving information regarding the hospital navigation, the consulting doctor etc.
  • Help for non-English speakers: Iconography cards to help non-English speaking patients express themselves and seek help in case of emergencies or other situations.

As Arlen Meyers, MD, President and CEO of the Society of Physician Entrepreneurs, says in a report, although many good ideas come from the front line, physicians must also be encouraged to think innovatively about patient experience. An academic study also builds a strong case to encourage intrapreneurship among nurses. Given they comprise a large part of the front-line staff for healthcare delivery, nurses should also be given the freedom to create and design innovative systems for improving patient experience.

According to a Harvard Business Review article quoted in a university study, employees who have the potential to be intrapreneurs, show some marked characteristics. These include a sense of ownership, perseverance, emotional intelligence and the ability to look at the big picture along with the desire, and ideas, to improve it. But trust and support of the management is essential to bringing out and taking the ideas forward.

Creating an environment conducive to innovation is the first step to bringing about innovation-driven outcomes. These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott, which is among the top 100 global innovator companies, is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the Scroll.in marketing team and not by the Scroll.in editorial staff.