Rebuttal of SK Arora’s misleading article on e-cigarettes

This is a point-wise response to tobacco control activist Dr SK Arora’s article in Mail Today. Dr Arora advocates for a complete ban on safer alternatives based on questionable facts which belie his lack of understanding of tobacco harm reduction, the devices, as well as the science.


Why vapes being safer than cigarettes is a myth

Dr SK Arora

Electronic Nicotine delivery system (ENDS) in the form of e-cigarettes, vaping and recently introduced JUUL devices being used by the youth, especially the school-going and college-going children are the latest strategy of tobacco industry to lure youngsters.

Juul is not the tobacco industry but a startup co-founded by two Standford University grads in 2015 which has captured over 60% share in the world’s largest e-cigarette market, the US, as sales of tobacco companies decline. Juul has not launched in India yet, and the devices available through third parties cost between Rs 4,000 and Rs 6,000 with refills priced at nearly Rs 2,000, which school-going children cannot afford and sustain. This is scaremongering.

GATS 2 (Global Adult Tobacco Survey 2016-17) study has clearly shown the reduction in number of tobacco users by about 81 lakh in India. However, the use of e-cigarettes, vape devices and JUUL is increasing because the youth is not aware of the health hazards of these products and moreover, these devices appear to them as attractive, cool, hi-tech and easy to carry. They are also easily hidden from parents and teachers. They also come out in appealing flavours and are wrongly perceived as less harmful than the traditional tobacco products.

There are two other key takeaways from GATS 2 – one is that the decline is not uniform and some states like Punjab and Tamil Nadu have recorded increase in tobacco use, which indicates the current tobacco control measures are not working. Moreover, the decline over a seven-year period is just 6%, at which rate it will take decades to eliminate tobacco use. A million people are dying from tobacco every year in India. Millions of lives will be lost if we do not substantially accelerate this decline. There is thus urgent need to increase quit pathways (e-cigarettes have led to a historic smoking decline in the UK, while HnB has led to 20% decline in Japan) and not limit them further with bans.

Busting myths

The JUUL is a type of e-cigarette that resembles a flash drive. It has two components: the base includes the battery and temperature regulating systems and the upper part has e-liquid cartridge containing nicotine and other flavouring chemicals. The nicotine content is 0.7ml (59mg/ml) per pod which is approximately equivalent to one packet of cigarette or 200 puffs. So, consuming one JUUL pod a day means consuming nicotine equivalent to a pack of cigarettes a day. The nicotine content per puff in such devices is comparatively higher when compared to traditional cigarettes.

The majority of harm from smoking comes from the combustion of tobacco which produces tar and releases about a hundred carcinogens. In e-cigarettes there is no combustion, hence no tar. This makes them substantially safer, as found by numerous respected research bodies who have been at the forefront of tobacco research and some of whom have led the fight against its use. They include – Public Health England, American Cancer Society, US National Academies of Sciences, Engineering and Medicine (NASEM), US FDA, British Lung Foundation, Cancer Research UK, Cochraine Tobacco Addiction Group and Royal College of Physicians, UK.

Nicotine is not the most dangerous element of tobacco smoke. It causes dependence, just like caffeine and with quite similar effects, but nicotine by itself does not cause cancer.

Juul pods are now also available in 20mg variants.

Similarly, ‘Heat Not Burn’ products are being introduced by tobacco industry, claiming them to be safer than traditional cigarettes, which is again a myth. There are no long term studies on the safety profile of all these devices, hence their claim of being safe are objectionable.

How many drugs have been tested for 20 years (long-term studies) before being put on shelves? There is enough credible evidence to act now and not wait for millions more to die before we make safer alternatives available publicly. An attempt is being made here to conflate HnB with vaping to confuse people. The products have different risk profiles, though both are much safer than cigarettes. E-cigarettes for instance do not contain tobacco, while HnB products do. This shows lack of understanding of safer alternatives.

Most of these devices are available on online markets with offers of discounts. Students get away with puffing JUULS in class and home as parents and teachers may not recognise it as anything other than a flash drive. That is why a chapter on tobacco control in school curriculum is essential to sensitise students, teachers and parents altogether in one go.

Sensitisation and awareness are important and welcome, but certainly not dissemination of false information. People need to be given accurate information so that they can make the right decisions. The Juul ‘problem’ is a predominantly an American experience, born more out of ideological opposition than facts, and not reported in any other country where the product is available, including the UK. Besides, CDC data does not support the claim that non-smoking teens are taking to vaping in droves as both smoking and e-cigarette use among teens continues to decline.

E-cigarette aerosol contains harmful and potentially harmful substances, including nicotine, heavy metals like lead, volatile organic compounds, and cancer-causing agents. Some research studies have shown that nicotine alone can mutate the genome and initiate cancer.

The presence of these elements in e-cigarette vapour is far lower than in combustible cigarettes, and metals are present at levels that are unlikely to cause harm, just as the metals present in food cooked in metal utensils are at trace levels.

No research has shown nicotine initiates or causes cancer. This is a flat lie.

Children and adults have been poisoned by swallowing, breathing, or absorbing e-cigarette liquid through their skin or eyes.

Far more children have suffered from coming into contact with phenyl used to clean toilets or by lighting matches. Accidental misuse mandates better safety guidelines, not banning, since then we should have banned phenyl, medicines which children accidentally swallow, hair dyes, etc.

Double damage

Researchers from University Hospital Schleswig-Holstein in Germany monitored participants’ vitals during and after they had smoked a cigarette, e-cigarette, or nicotine-free e-cigarette. As per results, e-cigarette adversely affected blood pressure and heart rate and effects were long-lasting as compared to traditional cigarettes.

This is a small study of 15 smokers whose vitals were monitored after just 5 minutes of use. Hardly a research to use for making policy claims.

Nicotine exposure during the periods of significant brain development such as adolescence, can cause lower impulse control and mood disorders. This can make young brains prone to addiction to other drugs, such as cocaine and methamphetamine.

Nicotine’s ill-effects on developing brains is known, even though these studies are conducted on mice not humans. Teen use should be prevented, but most for cigarettes since 9 out of 10 smokers started smoking when they were under 18 years of age. Besides, technology devices offer more effective means for prevention, from bluetooth locks to biometric switches, than relying on the conscience of the local panwala as is the case with cigarettes. 

It is also mentioned that as per US Public Health Service Surgeon General Report, e-cigarette products can also be used as a delivery system for marijuana and other illicit drugs.

Cigarettes are far more predominantly used to smoke marijuana.

A study by CDC (Centre for Disease Control) found that many adults are using e-cigarettes in an attempt to quit smoking. However, most adult e-cigarette users do not stop smoking cigarettes and are instead continuing to use both products (known as ‘dual use’). Campaigning for e-cigarette as a cessation device is completely a myth and unethical.

This is a false claim. According to a CDC report, nine million Americans have quit smoking with e-cigarettes (pdf), along with 2.8 million in UK, 1.2 million in France, 1.5 million in Russia, 1.38 million in Italy, a million in Malaysia, 711,000 in Indonesia, 308,000 in Canada, and many more millions across the world. This is direct evidence of the efficacy of e-cigarettes in helping smokers quit. In fact, e-cigarettes are now the most popular means to quit smoking in many countries (pdf).

On dual use, many NRT users also smoke cigarettes while attempting to quit. Should we ban NRTs? Every smoker has a quitting trajectory, and reducing the number of cigarettes gradually works for many. 

Nicotine therapies are to be prescribed by a qualified therapist so that the dose is regulated but in case of e-cigarettes or vaping, the dose cannot be regulated and self therapy only leads to shifting from one addiction to another and may also cause acute accidental toxicity.

It is a false claim that NRT (nicotine gums and patches) sales are regulated. They are available freely without age checks, even on Amazon. Moreover, NRTs have a low success rate, of barely 7%, with key drawbacks which e-cigarettes address. No wonder that use of NRTs is declining worldwide as smokers find e-cigarettes a more effective means to quit. 

It is also not factual to claim nicotine strength in e-cigarettes cannot be regulated. It can be, and smokers gradually decrease nicotine strength over time, giving them a quit pathway to reduce nicotine levels to zero. Again, Dr Arora shows no knowledge of how e-cigarettes work while calling for banning them. This mad drive against something which they have not taken the effort to understand is costing human lives.

It is mentioned that India has a large number of smokers (100 million) as compared to Britain (7.2milion). Moreover, the level of awareness and sensitisation in view of low literacy among people especially in rural areas in India is a big hurdle to advocate such policies and not advisable. So policies in UK may not be effective in India.

This is a strange circular argument. Half the article is about the claimed effects of Juul on the American population and why that should be the reason for us to prohibit it, and now we are claiming that the positive, proven effects of safer alternatives because are not applicable to India? You cannot argue both sides.

Secondly, low literacy is precisely the reason for very low desire to quit in India as people are not fully aware of the ill-effects of tobacco. While failing in that mission, low literacy is being used to deprive people of safer alternatives! It is a fact that it requires far more effort to educate and convince someone to give something up completely than to switch them to a lower-risk alternative. This is why harm reduction is a lot more pragmatic and effective approach than the fantasy goal of elimination.  

Complete ban

No doubt that all kinds of tobaccos including traditional cigarette/bidi should be banned but till the time they are banned, they have to be restricted/regulated under COTPA. Due to enforcement issues and tobacco industry’s interference, we have not been able to regulate them fully;

Another highly circular argument: If tobacco industry interference is why combustibles cannot be banned and the tobacco industry is supposedly behind these technology products, then why are they being banned despite tobacco industry interference, since then cigarettes should also be banned.  

The truth is the government’s reluctance to let go of tobacco tax and its efforts to protect this revenue by killing off competition (ITC shares shot up after the central advisory on e-cigarettes; the government owns nearly a third of ITC). It is now using tobacco control activists like you to push its agenda without you for a moment considering the number of lives will be lost through these anti-people actions.

therefore it is dangerous for new products like e-cigarettes to enter this list. There should be a complete ban on similar devices and this will boost the public health by preventing large number of diseases like cancer, TB, diabetes, hypertension, chronic lung disorder, brain stroke, heart attack and many more.

Which of these ailments are not caused by cigarettes? On the other hand, there is no evidence any of them are caused by e-cigarettes. Why then advocate for a ban on something which is 95% safer and pass off pushing for a ban on the far more harmful product? Is this public service? Is this not wilful genocide of millions of smokers in our country?


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