Indonesia, one of few countries (alongside the United States) not to be a party to the WHO’s Framework Convention on Tobacco Control (FCTC), formally integrated vapes into its regulatory framework in 2023.

With the world’s fourth-largest population at over 280 million people, spanning more than 17,000 islands between the Indian and Pacific oceans, the country is a critical front in the global battle over tobacco harm reduction.

Men’s smoking rate is extraordinarily high there. A 2021 WHO report found 34.5 percent of Indonesian adults—70.2 million people—used tobacco. A stark gender split translated to 3.3 percent of women and 65.5 percent of men.

Smoking has increased significantly in the past 20 years. The Global State of Tobacco Harm Reduction cites even higher estimates—with a projection that men’s smoking rate will reach 83.5 percent in 2025, though women’s will decline.

The situation, you might think, is crying out for tobacco harm reduction. Yet tobacco control activists claim the country would be better off banning vaping.

Among the suggested reasons why smoking is expected to keep increasing at least until 2029 are cultural acceptance, failures of tobacco control efforts, aggressive marketing by tobacco companies and tobacco products’ low prices. Most sales are of a locally produced, clove-flavoured cigarette called kretek.

The situation, you might think, is crying out for tobacco harm reduction, which has prompted mass smoking cessation in a number of wealthier countries. Yet even as Indonesian vape regulation develops, tobacco control activists have continued to claim that the country would be better off banning vaping.

Such calls have a long history in Indonesia, with deliberations in the health administration as early as 2016. The strongest push came in 2019, after the US’ so-called “EVALI” outbreak created panic around the world. “We want to ban, not limit, vaping and e-cigarettes,” Anung Sugihantono, the health ministry’s director general of disease control and prevention, said at the time.

Indonesia’s government ultimately opted for regulation instead. But this has not stopped groups like the Southeast Asia Tobacco Control Alliance (SEATCA), a nonprofit funded by Bloomberg Philanthropies, from amplifying calls for prohibition and false claims that vapes are as harmful as cigarettes. Both SEACTA and another Bloomberg grantee, the Campaign for Tobacco-Free Kids, have helped cast doubt on media and public support for vaping in Indonesia.

A network including other Bloomberg grantees, such as the Saw Swee Hock School of Public Health in Singapore, has sought to pressure Southeast Asian nations by repeatedly highlighting vape bans in the region, playing up their supposed positive outcomes, and arguing that such bans can avert a looming youth vaping crisis.

These groups offer the usual health claims about vapes, neglecting to compare their risks to those of the cigarettes they can replace. Meanwhile regulation requires significant resources for formulation, monitoring and enforcement, they argue, which Indonesia cannot afford.

Others say that an estimated tenfold increase in vape use—from 0.3 percent of the population in 2011 to 3 percent in 2021—includes a sharp rise among adolescents, and blame legalization for permitting the vape industry to promote its products.

Saigain pushed back on the claim that regulation has an unacceptable price tag: On the contrary, it “generates tax revenue that can fund public health initiatives.”

Yet Indonesia is also home to experts who defend the path it has taken, and warn of the consequences if the country were to join the 34 others, including many in Asia, which have imposed prohibition.

“Regulating e-cigarettes balances harm reduction, public safety, and consumer choice by providing adult smokers with a less harmful alternative and allows the government to enforce safety standards,” Harris Siagian, managing director of the Indonesia Development Foundation, told Filter.

Saigain noted the evidence that vapes are “an effective tool for smoking cessation,” and pushed back on the claim that regulation has an unacceptable price tag. On the contrary, it “generates tax revenue that can fund public health initiatives,” he pointed out.

“Although the regulation of e-cigarettes could require the use of existing resources for public health campaigns, law enforcement and monitoring, completely banning e-cigarettes is not a cost-free solution,” Siagian emphasized. “The ban could lead to an increase in law enforcement expenses, a loss in tax revenue, and the emergence of potential public health risks as a consequence of illicit trade in low-quality products.”

Siagian’s organization conducts economic research and policy and community development, so he is well aware of estimates that smoking-related illnesses cost Indonesia over 290,000 lives each year. The economic cost is meanwhile over $14.6 billion, or more than 1 percent of the country’s GDP. By banning vapes, Indonesia could exacerbate these harms and place further burdens on its health care system.

It could also “drive e-cigarettes into the illicit market and limit safer options for smokers,” Saigan said, “making regulation the more practical and balanced approach.”

“Regulating vaping will optimize the beneficence and minimize the maleficence of nicotine products. Human rights must also be protected.”

“Banning vaping will create more problems for the government, including trading of illicit products,” agreed Professor Amaliya Amaliya, of the Dental Faculty of Universitas Padjadjaran, Bandung. “In addition, we will miss the opportunity to have the benefit of vaping as an aid for reducing and quitting smoking for smokers unwilling to quit.”

“In contrast, regulating vaping will optimize the beneficence and minimize the maleficence of nicotine products,” Amiliya, who has authored research on vapes, told Filter. “Human rights must also be protected and facilitated.”

Banning tobacco harm reduction products was first proposed as an optional regulatory pathway at the WHO’s 2014 FCTC conference in Moscow. Vaping was then a nascent technology which few understood well.

Evidence of its relative safety and strong efficacy for smoking cessation has since mounted. Yet a number of nations in Global South have opted for bans, under pressure from a hostile WHO and international tobacco control organizations.

Such groups claim that vaping will create dual epidemics in low- and middle-income countries (LMIC) which are already struggling to control high tobacco use; divert resources away from current tobacco control efforts; negatively impact people who don’t smoke, especially youth; and enable industry interference in policy discussions.

Harm reductionists call prohibition a form of “philanthropic colonialism,” through which powerful Western interests undermine people’s right to health.

Harm reductionists, on the other hand, contend that vape bans in LMIC are overly simplistic, self-defeating in addressing the complexities of tobacco use, and create new harms through enforcement and violent struggles for control of illicit markets.

Prioritizing banning safer alternatives to combustibles, which cause 8 million annual deaths, is inherently illogical, they note. They call prohibition outdated, unrealistic and patronizing—a form of “philanthropic colonialism,” through which powerful Western interests undermine people’s right to health.

Of 10 Southeast Asian countries in the ASEAN grouping, five have imposed vape bans. Their stories are illustrative. Singapore, despite threatening a steep fine of $1,500 for using a vape ($15,000 for a repeat offense), is seeing an uptick in use. Thailand’s illicit vape market has grown significantly even though it has banned vaping since 2014. In October, Thai customs seized $100,000 worth of vaping products in just 10 days, prompting one senior minister to propose legalization, though this was later shot down by the health ministry.

In Malaysia, which in 2023 removed nicotine e-liquids from its “poisons” list, former customs director-general T Subromaniam said in a recent interview, “It is better to regulate and control these products … thus preventing the mushrooming of illicit trade,” adding that, “If we wish to nudge consumers towards alternative nicotine products, their fiscal treatment should be more favourable than the one on traditional nicotine products.”

Saigan called for the development of regulations which take into account local social norms and smoking patterns.

High excise taxes on vapes, which compare to and in some cases exceed those on combustibles in both Malaysia and Indonesia, also concern Siagian for their ability to impede tobacco harm reduction even without a ban.

“This makes e-cigarettes less affordable, especially for smokers seeking a safer alternative,” he said. “As a result, many smokers continue using combustible cigarettes, which are often cheaper, despite higher health risks.”

Saigan called for the development of regulations which take into account local social norms and smoking patterns. “The Indonesian government could establish mandatory quality standards for harm reduction products, implement strict age verification and vendor licensing, restrict marketing aimed at youth, and set minimum pricing policies to discourage youth access while promoting lower-risk alternatives,” he suggested.

“Additionally, ASEAN countries could benefit from regional coordination on product standards, risk-proportionate regulations, capacity building for enforcement and testing, and integrating tobacco harm reduction into broader tobacco control strategies,” he concluded.

Indonesia, with a huge and relatively young population smoking at high rates, faces a public health time bomb. Whether it can find a path to promote mass switching to safer products is a question of vital importance. And the outcomes of whatever approach it takes will resonate far beyond its shores.

Photograph by Danumurthi Mahendra via Flickr/Creative Commons 2.0

Both The Influence Foundation, which operates Filter, and the Indonesia Development Foundation have received grants from Global Action to End Smoking. Filter’s Editorial Independence Policy applies.

The post Will Indonesia, a Key Tobacco Control Outlier, Keep Vaping Legal? appeared first on Filter.

“I felt affected financially, since I had bought the device to use on the trip and it was new,” RNB, who requested that his full name be withheld, told Filter. “There was also moral embarrassment as I was called out in front of other people, and anger and sadness at the persecution of vape users.”  

A global, coordinated tobacco control network has resulted in policies being imitated. Perhaps the best known example is New Zealand’s controversial generational ban on cigarette purchase, which, despite being revoked there over various concerns, has found its way onto the agenda of the United Kingdom and other Western nations.

But cross-pollination of tobacco control measures is most prevalent in the Global South, where a lack of robust local research to guide policymaking helps international prohibitionist groups wield greater influence. This is especially true around novel nicotine products, with India, Mexico, Taiwan and Brazil among countries to pass similarly worded laws, along with policies that squeeze citizen freedoms.

What might sound a minor inconvenience is far more than that to a traveler who has switched from cigarettes, due to arrive in a place where vapes might not be readily available. Cigarettes are always available.

Prohibiting passengers from carrying vapes on flights, despite personal use not being banned by the country in question, is one egregious example. What might sound a minor inconvenience is far more than that to a traveler who has switched from cigarettes, and is due to arrive in a place where vapes might not be readily available. Cigarettes are always available.   

Brazil recently attempted this policy. But authorities hastily rescinded it after loud, sustained complaints from nicotine consumers and tobacco harm reduction advocates.

The template emerged five years ago in India. The text of the country’s 2019 vape prohibition bill omitted to mention that personal use and possession of vapes is not a crime—by the government’s own admission, such a ban would not hold up in courts—though external assurances were issued that use would not be prosecuted. A month later, however, the Indian aviation authority barred vapes on flights, citing the new law. The issue has been stuck in courts since.

Brazil has banned the sale and importation of vapes since 2009. In late 2023, after two years of deliberations, the national health regulatory agency, ANVISA, announced it would hold public consultations on amendments to the prohibition, mainly updating the wording, even as the Senate was deliberating on a bill to regulate vapes.

People who vape in Brazil were exasperated.

“ANVISA ignored science and the wishes of Brazilians, maintaining the ban on e-cigarettes while over 80 countries have embraced tobacco harm reduction and allow controlled sales of vaping devices,” Alexandro Lucian, a Brazilian consumer activist and researcher, told Filter. “This harms millions of e-cigarette users and prevents over 20 million smokers in Brazil from having access to safer nicotine products.”

Like in India, just one month later and despite the assurances, Brazil’s aviation authority, ANAC, imposed a total ban of vapes on flights.

Lucian is the president of DIRETA, a nonprofit representing Brazilian vapers. The group has been protesting against ANVISA’s anti-vaping stance since 2022, when it launched an online petition signed by 10,000 people. It also held protests outside ANVISA’s office during public consultations held in December and February, calling the new regulatory text “flawed and open to misinterpretation.” The protests gained substantial media attention.

Lucian with fellow protesters at Brazil’s Senate

Facing mounting pressure, ANVISA Director Daniel Pereira stated during a public consultation, “It is important to clarify that the proposed rule does not aim to criminalize the use of these products, but to maintain the prohibition of economic activities.” ANVISA later outlined these supposed consumer protections on its website before approving the new text in April.

But like in India, just one month later and despite the assurances, Brazil’s aviation authority, ANAC, imposed a total ban of vapes on flights, citing the new ANVISA text.

ANAC had previously followed the international norm of allowing vaping devices in carry-on luggage. It noted the change on its website on May 8, though communication to airports and airlines was inadequate, which resulted in haphazard implementation and harassment of unsuspecting vape users.

RNB, whose vape was confiscated by airport security in Campina Grande, said he was completely unaware of the new rule. He attempted to argue with the officials, but in vain. Other vape users told Filter of experiencing similar confiscations at certain airports. 

While some vented on social media, Lucian used Brazil’s formal right to information channels to seek a clarification from ANAC. 

The aviation authority responded in early July, stating, “Electronic smoking devices powered by batteries cannot be transported on aircraft, in checked baggage nor in hand luggage, in accordance with the new rules.”

Lucian and his colleagues pressed ANAC further, with more social media posts and another request—this time pointing out the discrepancy with ANVISA’s assurance that personal use of vapes is not prohibited. 

On July 16, three months after imposing the ban, ANAC responded by communicating the  reversal of its decision: “We clarify that the delay in dealing with this issue was mainly due to a process of harmonizing understanding with ANVISA, which resulted in a change of view. The devices are now permitted to be transported as hand luggage.” 

The U-turn, ANAC said, was in response to “numerous complaints from passengers, widely shared on social media.”

ANAC later updated its website, and confirmed its U-turn in response to an email query from Filter. “The national civil aviation agency has authorized the transport of electronic cigarettes on all domestic flights in Brazil, allowing them to be carried as hand luggage,” it said.  

The decision, it continued, was in response to “numerous complaints from passengers, widely shared on social media, who were being prevented from boarding with their devices at airports such as Rio de Janeiro and Campo Grande.”

Asked whether ANVISA’s decision to publish a poorly written text, despite warnings it could be misapplied, was deliberate or due to incompetence, Lucian said, “I can only speculate, but it seems they chose the wording carefully and tried to indirectly ban use and possession of vapes, waiting to see if consumers and the society react. ANAC’s decision to correct its error is a victory, but many people lost products that had helped them quit smoking, and some may have been forced to return to cigarettes.”

Lucian also pointed to the role of international nonprofits such as Bloomberg Philanthropies and its partner, the Alliance for Tobacco Control (ACT). He estimates that ACT has received up to $3.75 million in funding for anti-vaping efforts in the country. Brazil is among the top few priority nations in Bloomberg’s latest call for grants, which includes up to $400,000 in funding to “support the maintenance of Brazil’s ban on e-cigarettes.” 

Consumer wins like this one can energize efforts elsewhere. 

This highlights the immense funding gap between anti-vaping advocacy groups and volunteer-run consumer organizations like DIRETA. Consumer organizations are routinely smeared as industry front groups, despite DIRETA “choosing to not accept money from the tobacco industry,” according to Lucian.

But consumer wins like this one can energize efforts elsewhere. 

“The reversal of the flight ban policy in Brazil is to be welcomed, and can be instrumental in persuading the Indian judiciary about the illegality of harassing e-cigarette users at airports when use is not prohibited,” senior counsel Dr. Farrukh Khan told Filter. Khan has filed petitions to the Delhi High Court, on behalf of two vapers, in a bid to revoke India’s flight ban.

Brazilian advocates face a long road ahead, however. “In a context where regulation often blurs into authoritarianism, ANAC’s decision appears to be a response to popular dissatisfaction,” Claudio Teixeira, the editor of Brazilian online magazine Vaping Today, told Filter. But he questioned “whether this represents a true victory or merely a superficial concession, while failing to address the deep disconnect between health policies and the real needs of consumers.”

The country, he said, is experiencing “a growing wave of scientific denialism, fuelled by a moral-religious capitalist bureaucracy infiltrating various sectors of public administration.”

Brazilian consumers’ ultimate goal is to end the ban on vape sales. They’re now rallying behind the Senate bill that proposes regulating these harm reduction options.

Top photograph by Victor via Flickr/Creative Commons 2.0. Inset photograph courtesy of Alexandro Lucian.

The post Brazil Scraps Flight Ban on Vapes, in Win for Consumer Advocacy appeared first on Filter.

Cheered on by the World Health Organization and allied groups, India’s government has now obstructed research on tobacco harm reduction (THR) products and gagged the media from discussing adoption of THR strategies.

India is home to 120 million adults who smoke, the majority of whom are poor with strained health-care access. Cancer is projected to increase in India in the coming years, and 27 percent of cancers are attributed to tobacco use (which includes smoked bidi rolls and traditional chewable forms, as well as cigarettes).

Risk reduction can play a vital role in these conditions, and has been identified by Dr. Balram Bhargava, former director of the Indian Council for Medical Research, as a key approach to reducing the country’s cancer burden.

The directives amount to a de facto ban on investigating the risk continuum of nicotine products, and their health impacts among Indian populations.

Yet despite the enormous costs of tobacco use in India—1.35 million deaths a year, economic losses of over 1 percent of GDP—Indian doctors receive no training on preventive interventions or mitigating tobacco-related harms. 

The WHO’s campaign against lower-risk nicotine alternatives, propagated aggressively by anti-tobacco groups funded by Bloomberg Philanthropies, has led to further hardening of official positions in India.

On December 15, the day after WHO issued its latest dire warning against vaping, the National Medical Commission, a constitutional body that lays down policies for medical education in India, directed all doctors to refrain from conducting or participating in research on vapes and heated tobacco without seeking its approval and that of the health ministry. A similar instruction, issued to state-funded educational institutions in 2019, had already driven ethics panels to blindly reject THR research proposals. 

Together, these directives amount to a de facto ban on investigating the risk continuum of nicotine products, their varying impacts on health, and the viability and effectiveness of switching strategies among Indian populations.

The latest restriction, ostensibly to promote “responsible research,” is being viewed as an attack on both academic freedoms and public health.

“The possibility of turning India from a cancer capital into one where millions of adult smokers can lead healthier lives has gone up in flames.”

“Research is an integral part and the backbone of a progressive nation,” Dr. Aparajeet Kar, an interventional pulmonologist in Assam, told Filter. “With a ban on ENDS [electronic nicotine delivery systems] and now an effective ban on research, the possibility of turning India from a cancer capital into one where millions of adult smokers can lead healthier lives has gone up in flames.” 

Vaping nicotine is demonstrably safer than smoking conventional cigarettes or bidis, and many countries have seen dramatic declines in smoking after its introduction. In contrast to India, these nations have adopted a scientific approach in tackling tobacco-related health burdens, said Dr. Kar, who is the director of the Association for Harm Reduction Education and Research (AHRER), a pan-India body of medical professionals seeking integration of THR in tobacco control. 

Researchers working in the THR field say tobacco use in India is a complex issue, which cannot adequately be addressed with boilerplate measures such as tax hikes and bans. While over 40 percent of adult Indian men consume tobacco, with prevalence particularly high in poor and rural communities, smoking is also rising sharply among urban women—situations that require pragmatic and differentiated policy responses. 

It’s notable, too, how research into cannabis and opium is permitted and funded, when tobacco use severely impacts far more Indians.

“The wide spectrum and high tobacco use in India is both a health and social concern, depriving many families of breadwinners and contributing to inequalities,” Professor Debjani Banerjee, a social science researcher at VES Business School in Mumbai who has conducted studies on vaping and oral nicotine, told Filter. 

“Studies have identified a significant desire to quit among tobacco consumers and e-cigarettes have emerged as an effective alternative support,” she continued. “Then why are policymakers imposing a ban on such research which can help validate the truth, especially as it could prove its worth in reducing tobacco mortality and morbidity?”

Speak No Harm Reduction

The new research clampdown came just months after a comparable attack on media freedoms. In May 2023, the ministry of information and broadcasting, in an unprecedented move, barred print and digital media from publishing anything that “directly or indirectly promotes the use of electronic cigarettes.”

The diktat was prompted by a high-profile panel discussion on THR. This included, among eminent Indian and international experts, a member of Niti Aayog, the top policy think tank of the Indian government. The 35-minute discussion highlighted various perspectives on THR, including opposition to it. It made no mention of any specific products. But because some panelists were critical of the vape ban, the health ministry branded the event as vaping “promotion.”

In response to the ensuing media gag, panelist Dr. Nimesh Desai, a psychologist and former director of the Institute of Human Behaviour and Allied Sciences in New Delhi, told Filter, “As far as I saw it then and see it now, that session was one of the science-industry dialogues at a business summit, so clearly had shades of opinions on possible future course of actions [in tobacco policy].”

With no discernible media resistance, the circular has succeeded in wiping out THR debate. Media houses now relegate reporting on vaping and THR developments to junior staff. Their articles are peppered with quotes from medical professionals with no exposure to THR, nor any understanding that vaping, heated tobacco and modern oral nicotine products fall low on the risk spectrum. Instead, these “experts” echo the Bloomberg line by portraying such interventions as an industry tactic to hook young people.

“I worry about the chilling effect this will have on public discourse around safer nicotine alternatives which can save many lives.”

Another participant in the panel debate, Dr. Kiran Melkote, orthopedic surgeon at Fortis Hospitals in Gurgaon and also an AHRER director, said the idea that talking about evidence-based solutions and reducing harm from tobacco use undermines public health—especially when current approaches are failing—is “deeply offensive.”

“I worry about the chilling effect this will have on public discourse around safer nicotine alternatives which can save many lives,” he told Filter.

The reason cited for the gag was that discussing vapes in a positive light amounts to promotion, which violates the ban. But can a law carry within it a penalty for criticizing it?

“The freedom to analyze and criticize legislative and executive actions is inherent to the rule of law,” legal counsel Pingal Khan, a partner at Ashlar Law in Bangalore who has been involved in vaping litigation, told Filter.

“Making a law or interpreting it to mean it cannot be questioned is an attack on Article 19 [the right to freedom of speech] as well as the fundamental principles on which our Constitution stands,” he continued. “The government’s position is absurd and is likely to result in executive overreach and arbitrary application of the directive, causing harm to the evolution of dialogue and policies in the health and harm reduction policy space.”

International experts have also responded with dismay to India’s backsliding on academic and media freedoms, which appears to be timed for showcasing at the upcoming COP10 international tobacco control meeting in Panama.

As if in a parallel universe, many Indians are voting for their health by switching from combustible tobacco to unregulated vaping products.

“There is a vast difference between violating a law and questioning its basis,” David Sweanor, law professor and chair of the Advisory Board of the Centre for Health Law, Policy and Ethics at the University of Ottawa, Canada, told Filter. Sweanor was an international invitee on the panel that prompted the media directive.

“There is no question there are huge differences in risk between different nicotine products,” he continued. “Whether it is good public health policy to enact a ban on the least hazardous ones is clearly worth discussing. All the more so when the policy is associated with a vast increase in the market value of cigarette makers, and millions of lives could end tragically prematurely if the law is indeed misguided.”

India’s government, it’s worth remembering, holds a large stake in ITC Limited, a tobacco company that dominates the Indian cigarette market.

Meanwhile, as if in a parallel universe and despite the ban and growing censorship, India’s illicit vape market continues to mushroom. Many Indians are voting for their health by switching from combustible tobacco to unregulated vaping products. These have become available in small towns across the country. They’re sold in defiance of the government, the WHO and Bloomberg, but without age verification or consumer protections.

Photograph by Santeri Viinamäki via Wikimedia Commons/Creative Commons 4.0

The post India Doubles Down on Vape Ban With Research and Media Censorship appeared first on Filter.

Put in perspective, the four-year infusion is meager compared to well over $2 billion invested in tobacco control by governments each year, according to the World Health Organization (WHO)—and insignificant when weighed against the global tobacco and nicotine products market of $941 billion in 2023. Yet, even though tobacco control funding accounts for only about 10 percent of Bloomberg’s overall giving, it is seen as his most impactful public contribution—directly affecting the lives of 1.3 billion people who use tobacco.

Bloomberg Philanthropies’ $1.58 billion expenditure over two decades in 150 nations makes it the largest private tobacco control donor in LMIC. Through funding to hundreds of governmental organisations and influential nonprofits, it has immense ability to influence national tobacco control policies. This is also true at the global level, where the organization has donated close to $1 billion to WHO for anti-tobacco efforts. Bloomberg has retained the prestigious WHO ambassador title since 2016.

“Bloomberg Philanthropies’ tobacco control grants are offered in return for policy amendments.”

While Bloomberg Philanthropies’ tobacco control work has often been a force for good, helping to gradually reduce direct and indirect tobacco harms, it is increasingly seen in a negative light in many LMIC. This is because of its tendency to push one-size-fits-all policies that either cannot be implemented or cause harm—especially its opposition to tobacco harm reduction measures in nations where they are vital, in the absence of public health care and medical coverage. 

These hardened policy positions, many activists say, fail to account for local contexts, cultures and needs.

“Bloomberg Philanthropies’ tobacco control grants are offered in return for policy amendments,” Joseph Magero, chair of the pan-African consumer advocacy group Campaign for Safer Alternatives, told Filter. “Unfortunately, their prohibitionist agenda has driven nicotine products, including cigarettes, to the black market, which is thriving in LMIC. Despite 44 countries in Africa having ratified the WHO Framework Convention on Tobacco Control, smoking rates continue to rise.” 

In at least one instance, national legislators intervened to prevent Bloomberg Philanthropies from interfering in their domestic policies.

“I welcome bona fide organizations that aim to promote public health in the Philippines,” Congressmember Estrellita Suansing told Filter. “However, what we have seen with Bloomberg Philanthropies and the organizations they fund, as far as the Philippines is concerned, is that the government agencies they give grants to are in effect incentivized to mimic their position on regulatory policies, even if this goes against the policy direction from Congress.” 

Suansing was referring to the grants received from Bloomberg-funded organizations by the Philippines’ Food and Drug Administration (FDA). These pushed the agency to take a prohibitionist approach to vaping products and oppose Congress’s efforts to provide with harm reduction alternatives to smoking. Adding vapes to the list of prohibited substances carries particular dangers in a country that has conducted a long and bloody drug war.

“We are following the lead of the United Kingdom and New Zealand in acknowledging that these [vapes] are less harmful than cigarettes.”

“There will be a disconnect when a foreign organization’s funding drives the regulatory policies of a government agency in a way that contradicts our national laws,” Suansing continued. “Congress gave the Philippine FDA the authority to regulate vapor products and heated tobacco products in 2020 under our tax law. However, we saw that the FDA had not been a balanced regulator when it issued draft regulations that included very expensive and time-consuming requirements, resulting in a de facto ban on these products.”

Suansing then filed a bill to insulate executive agencies from pressure from foreign interest groups, and Congress consequently passed the Vaporized Nicotine and Non-Nicotine Products (VNNP) Act in 2022.

“We are following the lead of the United Kingdom and New Zealand in acknowledging that these VNNPs are less harmful than cigarettes and should be made available to adult smokers to help them get rid of this deadly habit,” she said.

Philippines legislators succeeded in thwarting the Bloomberg meddling, but most LMIC are ill-equipped or unwilling to do so. 

Bloomberg-funded groups often celebrate the success of prohibitionist legislative efforts. That was the case in India, after it imposed a ban on nicotine vapes in 2019. The Union issued a release outlining how it had influenced the outcome. In Mexico, a legal advisor for Campaign for Tobacco-Free Kids was found in 2021 to have drafted the legislation for banning vapes which was presented in Parliament. 

“It supplants the expertise of local groups regarding the needs of the communities they serve with the dictates of a far-off American billionaire.”

Such instances have caused concern that the new round of Bloomberg funds will fuel a renewed push for the prohibition of safer nicotine alternatives in LMIC.

Michelle Minton, senior policy analyst at the Reason Foundation, highlighted many such incidents of interference in a 2021 report titled, “Exposed: Bloomberg’s Anti-Tobacco Meddling in Developing Countries.” She has described Bloomberg Philanthropies’ funding efforts as “philanthro-capitalism.” 

“Such large sums of money, particularly in countries with limited funding for charitable work, will almost certainly lead some parts of civil society to alter their priorities in order to qualify for grant money,” she told Filter, “supplanting the expertise of local groups regarding the needs of the communities they serve with the dictates of a far-off American billionaire whose main interest is in passing legislation rather than improving outcomes.”

Notably, Bloomberg Philanthropies states that it is not in favor of the prohibition of all vaping products, though it actively supports banning the flavors that people who switch from smoking find helpful.

A Bloomberg Philanthropies spokesperson declined to comment directly on the dissonance between this position and the Bloomberg-funded organizations seeking blanket bans.

In a 2021 letter to eminent scientists seeking dialogue on tobacco harm reduction, Dr Kelly Henning, who leads public health programs at Bloomberg Philanthropies, wrote:

“I want to reiterate; we are not calling for policies to prohibit the marketing of all e-cigarettes. We have not opposed the sale of tobacco-flavored e-cigarettes and are supportive of efforts to have the federal government do more to both protect youth and to ensure that the products that are made available to adult smokers who want to quit, do in fact, increase the chances of a cigarette smoker quitting altogether and where that is not possible, switching to the use of a product that is demonstrably less harmful, ideally as a pathway to quitting.”

Bloomberg Philanthropies spokesperson Veronica Lewin declined to comment directly on the dissonance between this position and the Bloomberg-funded organizations seeking blanket bans on all vapes—or on whether Bloomberg Philanthropies may hold divergent views on vape policy in Western nations and LMIC.

“Bloomberg Philanthropies and partners utilize a multi-pronged approach, including protecting people against secondhand smoke and raising taxes on tobacco, to strengthen public health and prevent premature deaths related to smoking,” she told Filter. “We have always maintained that if the tobacco industry was serious about health, they would take the formal steps to get e-cigarettes approved as a cessation tool. But they haven’t. Instead, the industry tries to block implementation of tobacco control measures and is increasingly targeting young people with flavored products in the hopes of making them lifelong customers.”

Some tobacco and vape companies have gone to lengths to obtain FDA authorization for their vaping products as “appropriate for the protection of public health” in the United States, where heated tobacco products have also been granted “modified risk” authorization. And in the United Kingdom, efforts to medically licence vaping products are already under way, though tobacco harm reduction experts have argued for them to be regulated as consumer goods to ensure they remain as accessible as tobacco products. 

It is impossible to see how banning or heavily restricting vapes serves the purpose of preventing smoking-related deaths in LMIC.

Vaping has long been demonstrated to carry vastly fewer harms than smoking. And the latest Cochrane Review found it to be more effective than nicotine replacement therapies for smoking cessation. 

In the UK, where vaping has been broadly welcomed, an estimated 4.3 million people now vape; of these, 2.4 million formerly smoked, another 1.5 million vape and smoke (and may be on a path to switching entirely), and just 350,000 have never smoked. Teen vaping in the US has also fallen significantly after an initial spike, and regular use among those who have never smoked has always been low. 

In light of such evidence, it is impossible to see how banning or heavily restricting vapes serves the purpose of preventing smoking-related deaths in LMIC.

“For its work to be meaningful in developing countries, Bloomberg Philanthropies should explicitly state it is against prohibition of risk-reduced alternatives to deadly smoking and local products,” Professor Roberto Sussman, president of the consumer advocacy group Pro-Vapeo Mexico, told Filter. Sussman has previously criticized Bloomberg influence on Mexico’s tobacco control policies. 

He continued that Bloomberg Philanthropies should also “provide funds for cessation facilities, help strengthen efforts to prevent sale to minors, reject prescription-only models for e-cigarettes and support tobacco harm reduction measures by halting demands that they be regulated in similar restrictive ways as cigarettes.”

Without such commitments, at least some of the new Bloomberg dollars flowing to LMIC are likely to do more harm than good.

Photograph by Mike Mozart via Flickr/Creative Commons 2.0

The post Will New Bloomberg Funds Spread Vape Bans in Low-Income Countries? appeared first on Filter.

On January 12, amendments to the Tobacco Hazards Prevention Act effectively cleared the legislative floor. Now, the legislation only awaits a presidential nod—a formality given that President Tsai Ing-wen is from the ruling Democratic Progressive Party that proposed it. 

The news, which arrives not long after the Philippines enacted relatively pro-vape regulations, has elicited strong reactions from consumers, policy experts and medical experts, who had some hopes that the tide might be turning in favor of tobacco harm reduction (THR). 

Taiwan appears to be emulating regulations in nearby Japan, where heated tobacco products (HTPs) are sold legally but nicotine vapes are prohibited. The availability of HTPs in Japan has seen a dramatic reduction in cigarette sales. But THR advocates will wonder why an option indicated to have an even lower risk profile—and shown to be a more effective smoking cessation aid than nicotine replacement therapy—is about to become formally illegal. Other Asian countries to have banned vapes include India and Thailand. 

The imminent ban includes use of e-cigarettes, with penalties of up to $330 for violations.

In Taiwan’s strained governmental nomenclature, HTPs have been classified “designated tobacco products” and are subject to regulation, while vaping devices have been accorded the category of “tobacco-like products.” The imminent ban includes use of e-cigarettes, with penalties of up to $330 for violations. (Previously, vapes had existed in something of a legal gray area.) 

This has ignited debate in Taiwan, a country of 24 million where 13 percent of the population smokes, including almost a quarter of men. While millions of upset vape users have been left in the lurch, anti-tobacco groups are meanwhile demanding HTPs be banned too. The law, which will likely come into effect in a month after the presidential assent, will inevitably force vape shops to close and a rapidly growing industry to shutter or go underground.

While it’s difficult to deduce the motivations for the legislative decision, Taiwan policy experts and vape users point to a combination of misinformation, financial considerations trumping public health, and the positions taken by World Health Organization’s Framework Convention for Tobacco Control (WHO FCTC) on novel nicotine alternatives.

“The issue did not have enough public discussion and the approach to harm reduction should be more thoroughly debated,” Simon Lee, the Taiwan policy fellow at Consumer Choice Center, a global consumer advocacy group in Washington, told Filter. “For instance, we have seen misinformation, especially with regard to nicotine, circulating among anti-tobacco activists. It is beyond reasonable doubt that Taiwan’s consumers deserve a much better outcome.”

Taiwan’s willingness to comply with WHO positions could be seen as a way to create pressure for its membership in the future.

Even though Taiwan has been repeatedly denied membership of the WHO, the rationales provided in the bill rely heavily on the agency’s positions. For heated tobacco, the bill refers to WHO’s 2020 statement that HTPs are tobacco products and FCTC guidelines should be fully applied to them. In the case of vaping products, references are made to FCTC recommendations in its conventions six and seven (held in 2014 and 2016) that nations should “prohibit or regulate them.” Taiwan’s willingness to comply with WHO positions could be seen as a way to create pressure for its membership in the future.

“We can certainly see the Taiwan government’s wish to play a much bigger role in global public health policymaking,” Lee said. “However, we have to point out that blind adherence to WHO and its subordinate institutions is not the way to go. It is clear that WHO acted unaccountably on many issues, including that of Taiwan’s membership. During the Wuhan pneumonia outbreak, the Taiwan government showed it can lead the global public health debate. It is now time for Taiwan to show the world what the best practices are, including that on harm reduction.”

Danny (Yu-Yang) Wang, who leads VAPE Taiwan, a tobacco harm reduction media and advocacy organization he founded in Taiwan’s capital of Taipei in 2017, told Filter that the government has listed many reasons for the ban—alleging that vaping is bad for health, causes “EVALI,” includes cannabis use, has “gateway” potential, leads to a youth epidemic, and so forth. Legislators have publicly reasoned that e-cigarettes are “complicated chemical products and hard to regulate, so it is better to ban them,” Wang said. But the fight for control over nicotine between the pharmaceutical and tobacco industries might, he continued, be at the heart of it.

“Tobacco is controlled by the tobacco companies while nicotine is in the domain of the pharmaceutical industry,” Wang said. “While the former got their way with HTPs, vaping products were banned because Big Pharma would not let go of its monopoly over nicotine.” He added that meanwhile, for HTPs, variants that have passed the US FDA pre-market authorization process will be allowed. “It is like Taiwan is the 51st state of America.”  

“To trade the health of the people for money just isn’t right.”

“Banning a substance has never worked, especially an addictive one,” said a medical professional who spoke to Filter on condition of anonymity, fearing retribution for speaking against government policies. “We know that the taxes from tobacco, which amount to the range of billions to tens of billions, are used on several government policies and to fund agencies, and have quite an impact on the government’s finances. But to trade the health of the people for money just isn’t right.”

Suggesting that the inevitable outcome of this ban will be an illegal market, he said, “Given the history of government ineffective enforcement on tobacco products, one can easily spot underage smoking everywhere. Vaping will be left with no other option than going underground.”

Vape users in Taiwan interviewed by Filter echoed this sentiment, along with resentment over the policy decision. “Politicians who voted for the ban should be held accountable,” Robin W.*, a 56-year-old Canadian living since 2000 in Taichung, a city in central Taiwan, told Filter. “Legislative voting here stems from an old system such that no individuals in the government can be held responsible. The people need to demand the names of those who voted for the vape ban. If something like that were to happen, I believe many of the politicians who are hiding under this archaic cloak would change their vote.”

Robin, who switched from smoking to vaping eight years ago after a health scare and has seen improvement since, said the ban is unlikely to deter vape users, though it could discourage people who currently smoke from making the switch. “It is going to be a lot more difficult to find supplies,” he said. “For those who can, I don’t think things will change much. There are so many laws here that aren’t enforced and police officers don’t care much about smaller fines. Of course, vapers will tend to be more careful about vaping in public. And there will be a general feeling of being ostracized by society more so than even now.”

“I am already getting links to continue vaping after the ban.”

There is so far little indication of organized consumer pushback against the ban, even if some hope the president will seek a rewrite of the bill. But Wang said about 3 million people have tried vaping or HTPs in Taiwan—a significant voting bloc that the government cannot afford to antagonize, especially ahead of the general elections due next year. “For this reason, I have initiated an email campaign for the Taiwanese to write to the president seeking review of the bill,” he said.

Meanwhile, despite heavy fines of up to $329,000 for selling, many vape vendors are gearing up to make a transition to the underground economy. “Prices will most likely go up, but not by as much as one might expect,” Robin said. “The stores sell their products at much higher rates than you can find on the internet, so people are used to that. I am already getting links to continue vaping after the ban.”

* Name abbreviated to protect privacy at source’s request.

Correction, January 24: This article has been edited to correctly represent Wang’s estimate of THR uptake. An earlier version wrongly characterized it as 3 million people having switched from cigarettes to vapes.

Photograph of Taipei by 毛貓大少爺 via Flickr/Creative Commons 2.0

The post Taiwan Is About to Ban the Use of Nicotine Vapes appeared first on Filter.

About 10 million people use SLT in Pakistan, comprising over 40 percent of overall tobacco use. Common products range from paan to gutka to naswar—all of which have been proven to be deadly.

In contrast, snus, a steam-pasteurized Scandinavian oral tobacco that is used by placing between the upper lip and gums, has long been known to carry far lower harms. In 2019, the US Food and Drug Administration (FDA) authorized risk-reduction claims to be made about some snus products. Meanwhile a modern variant, nicotine pouches, contains no tobacco and ranks even lower on the continuum of risk.

Both offer significant potential as safer substitutes to harmful SLT. Their efficacy remained to be demonstrated in a real-world South Asian setting, but that’s rapidly changing. Last week, new industry figures showed that Velo, a nicotine pouch product, had hit sales of 40 million pouches a month in Pakistan.

“Product substitution has been shown to be the most effective strategy ever used to reduce the death and disease toll from toxic tobacco products.”

Such rapid substitution—Velo launched in Pakistan only in early 2020—is clear evidence that despite the cultural, social and price adhesiveness of traditional smokeless products, harm reduction here is possible.

“Product substitution has been shown to be the most effective strategy ever used to reduce the death and disease toll from toxic tobacco products,” David Sweanor, an independent tobacco industry expert and adjunct professor at the University of Ottawa, told Filter. “The evidence from wealthy countries such as Sweden, Norway, Japan, the UK and New Zealand is stunning. The role of modern oral nicotine now puts the lie to those claiming substitution is not viable in lower-income countries.”

In Sweden, adults have largely replaced cigarettes with snus over the past few decades, and the government recently announced that smoking rates in the country have declined to 5.6 percent. In 2021, the UK—which has largely promoted vapes as tobacco harm reduction (THR)—recorded its lowest ever smoking rate. Although Japan has been hostile to e-cigarettes, it has almost begrudgingly welcomed “heat-not-burn” tobacco products, and has seen close to a 43 percent drop in cigarette smoking in half a decade. 

Lower- and middle-income countries, which bear the brunt of the world’s tobacco-related harms, could well be next.

Nihar Dholakia is steering his family’s century-old smokeless tobacco business in Gujarat, India, toward safer alternatives.

Even some traditional SLT manufacturers in South Asia are beginning to see the value proposition of modern oral products. Among them is Nihar Dholakia, who is steering his family’s century-old SLT business in Gujarat, India, toward safer alternatives.

“India has a long history of using smokeless tobacco in the form of dipping and chewing,” he told Filter. “Modern oral nicotine pouches, or tobacco-free snus, can play a massive role in helping ease the oral cancer burden in India. In the last two years of their presence in Pakistan, the use of toxic SLTs like gutka and naswar has dropped to a record low as exports of these goods to Pakistan from India have dipped. We may see the same in the Middle East and in parts of Africa soon.” (Eighty to 90 percent of oral cancers in India are attributed to SLT use.)

Yet the transformation that’s happening in Pakistan, like almost everywhere else, is occurring not with government support but in its absence.

“Currently, nicotine pouches are being sold and used in Pakistan in a regulatory vacuum,” Arshad Ali Syed, the head of the Alternative Research Institute (ARI), a research group based in Islamabad, told Filter. “We believe there is a need for sensibly regulating tobacco harm reduction products, including e-cigarettes, nicotine pouches and heated tobacco products. Additionally, the regulation should be appropriate to the risk these products pose to human health.” 

Neighboring India, where there are more than 200 million SLT users—double the number who smoke—is also yet to regulate for a harm reduction approach. That’s despite 350,000 annual deaths attributed to SLT use, and a recent parliamentary standing committee report highlighting the need to focus on SLT interventions. India banned the sale of e-cigarettes and heated tobacco products in late 2019.

“Reduced-risk oral tobacco substitutes are the key to lowering the burden of death and suffering, especially in socially and economically disadvantaged groups.”

“The Southeast Asian region has the highest proportion of people who use harmful oral tobacco mixed with additives,” Dr. Kiran Melkote, a Delhi-based member of Association of Harm Reduction Education and Research (AHRER), told Filter. “This also tends to be concentrated among the socially and economically disadvantaged groups.”

A major roadblock to product substitution is the stance taken by the WHO and its allies, who have routinely called for bans on emerging nicotine alternatives, irrespective of their risk profiles and potential to reduce high tobacco mortality and morbidity in the region. Recently, they opposed the approval sought by Pakistan’s health ministry for heated tobacco, while their pressure on the Indian government to enact its bans is well known, and there are ongoing efforts to get them banned in Bangladesh.

“Instead of continuing counterproductive efforts to block substitution, it is time for global tobacco control groups to embrace and enhance such interventions,” Sweanor said.

But so far, there appears to be less opposition to novel and risk-reduced oral products. That could be because, despite the enormity of the toxic SLT problem, the policy focus of governments and abstinence-oriented groups remains on combustibles. Further, the South Asian oral tobacco industry is unorganized and, in many cases, run with politicians’ direct or indirect participation—giving businesses protection from taxes, interventions and competition from the organized sector. Whether that situation lasts remains to be seen.

“The Swedish experience has shown the way—reduced-risk oral tobacco substitutes like snus and nicotine pouches are the key to lowering the burden of death and suffering, especially in socially and economically disadvantaged groups,” Dr. Melkote said. “It is time the governments take notice and start subsidizing and substituting these products on a large scale as part of the national tobacco control programs.”

Photograph of the Pakistan Monument in Islamabad by Yaarahmadd via Wikimedia Commons/Creative Commons 4.0

Both INNCO, of which the author was previously president, and The Influence Foundation, which operates Filter, have received grants from the Foundation for a Smoke-Free World. The Influence Foundation has also received grants from Reynolds American, Inc., a subsidiary of the manufacturer of Velo. Filter’s Editorial Independence Policy applies.

The post Pakistan Nicotine-Pouch Surge Brings Harm Reduction Hope in South Asia appeared first on Filter.

“For the first time in the legislative history of our country, we have achieved a national differentiated regulatory framework governing vaping products and HTP [heated tobacco products],” said Dr. Lorenzo Mata, a central figure in the Philippine movement for balanced regulation and head of the nonprofit Quit for Good. Among other features, the law requires separate designated public vaping areas where smoking is prohibited, creating clear distinction between the two.

While some Asian nations have banned the sale of safer nicotine alternatives, the Philippines model could serve as a key counterpoint.

Dr. Mata was speaking at the fifth Asia Harm Reduction Forum (AHRF) held in Manila on October 28, an annual conference that brings together doctors, policy experts and consumer advocates from across the continent where the majority of the world’s tobacco users live. While some Asian nations such as India and Thailand have banned the sale of safer nicotine alternatives, the Philippines model—enacted in July after intense opposition from anti-vape groups—could serve as a key counterpoint. (Previously, Duterte had banned vaping products through an executive order.)

“About half of the provisions of the Philippine vape law are intended to safeguard the welfare of minors,” Dr. Mata continued, adding that it prohibits minors from purchasing or using vapes and HTP, imposes strict restrictions on their display at points of sale and near schools, bars the use of flavor descriptors that may allegedly attract kids, and levies severe financial penalties for businesses that break these rules.

“This law was made as a harm reduction strategy to reduce the number of smokers and sway them to switch to less harmful products,” said its co-author, Congressman Ace Barbers, in his address to the conference. “It is not our goal to have nonsmokers, most especially underage Filipinos, be convinced to take up vaping. This is why this law, while allowing the switch to vaping for harm reduction goals, is very strict in its execution to prevent use by nonsmokers.”

This emphasis on preventing youth use would be criticized by many tobacco harm reduction (THR) advocates, when encouraging people of any age to switch—typically with the help of flavors—should be the overwhelming imperative. Yet the law represents an encouraging pragmatic compromise in the context of a country with draconian wider drug laws. It is progressive in that it allows products to carry proven risk-reduction claims, and is open to incorporation of scientific evidence and research data in governance strategies. 

A critical roadblock, however, is that tobacco research and harm reduction studies in LMICs remain abysmally scarce. To address this gap, public health researcher Dr. Rosana Ulep, chief of the dental services department at the Polytechnic University of the Philippines, presented a meta-analysis that contextualizes harms from smoking in the country in comparison to vaping and other factors.  

The data-rich analysis validates the harm reduction approach; the country has among the highest adult smoking rates in the world, with 10 Filipinos dying every hour from smoking-related diseases. While a sharp hike in tobacco taxes since 2013 led to an overall decline in the prevalence of smoking and related mortality, the total numbers of people who smoke and deaths remain the same or are rising, and the illicit market has swelled. Allowing and encouraging people who smoke to mitigate risk through differentially taxed and safety-checked nicotine alternatives will accelerate smoking decline.

The AHRF also saw presentations on THR policy and advocacy by experts and consumer groups who spoke about the necessity to adopt similar laws in other countries.

David Sweanor, an adjunct professor at the University of Ottawa who has studied tobacco policies for more than two decades, provided historical context for the opposition to THR products whose comparative safety and substitution potential for smoking is well established. “With innovation, there tends to be strong focus on unintended risk, without due consideration to the risk of inaction,” he said. “But innovation is impossible to halt, especially in the case of tobacco alternatives. The incentive is high for anyone to become a billionaire from selling safer nicotine products—they only need to capture one ten-thousandth of the $800 billion tobacco market. Consumers, too, are aware of tobacco risks and are willing to make the switch if given the choice. In Japan, for instance, cigarette sales have declined 50 percent in seven years as smokers switched to heated tobacco products.”

“The increasing smoking-prevalence and mortality gap between these two nations will ultimately prove who got it right.”

The largest nation opposing this innovation is India, which banned vaping and HTPs in 2019 despite more than 100 million of its citizens smoking tobacco, a million of whom die from related illnesses every year. Jagannath Sarangapani—a member of the consumer nonprofit Association of Vapers India (AVI), and a board member of International Network of Nicotine Consumer Organizations (INNCO), which comprises more than 30 national bodies—said the Philippine model will be useful for other LMICs that are considering how to regulate these products. “The increasing smoking-prevalence and mortality gap between these two nations will ultimately prove who got it right,” he said.

Asa Saligupta, who leads the consumer group ECST in Thailand, another country that has banned sales of safer nicotine alternatives, said, “Even our prime minister is in favor of lifting the ban, so vapers may be looking at a bright future.” However, he highlighted that at present there’s still rampant harassment of people who vape. Police continue to fine, arrest and even bribe vapers, despite the fact that personal use and possession are not prohibited.

Joey Dulay, the president of Philippines E-cigarettes Industry Association, which represents over 200 store owners, suppliers and manufacturers, said, “The vape law has struck an appropriate balance between product safety, prevention of unintended use and maximization of the potential for adult smokers to switch to better alternatives.” By ensuring only registered vendors, both offline and online, can sell these products, the government can also hope to raise more revenue while hampering unscrupulous illicit operators, he added.

But there is still some way to go before the Philippines’ 16 million people who smoke can reap the benefit, as the implementation of the law is still being worked out, said Pater Dator, president of the Vapers Ph, the country’s leading consumer nonprofit and the co-host of the event. He hinted at meddling attempts by some agencies in the ongoing deliberations, which raises concerns over the intent of the law being subverted.

“The WHO FCTC has failed the 8 million people who die from unsafe tobacco products annually.”

Consumers are too often excluded from tobacco control conferences, but their voices were a key part of discussions at AHRF. Giving voice to the concerns of tobacco and safer nicotine users, Nancy Loucas, the executive director of the Coalition of Asia Pacific Harm Reduction Advocates (CAPHRA), said that despite vapers having exercised their right to health by switching away from deadly combustibles, a right enshrined in UN and World Health Organization charters, they are treated as pariahs and looked down on by global health organizations.

Presenting a paper on the anti-THR stance taken by World Health Organization’s Framework Convention for Tobacco Control, she said, “The WHO FCTC has failed the 8 million people who die from unsafe tobacco products annually. Until there is a change, billions will continue to be harmed and die from a preventable cause.”

Photograph courtesy of AHRF

Both INNCO, of which the author was previously president, and The Influence Foundation, which operates Filter, have received grants from the Foundation for a Smoke-Free World. Filter’s Editorial Independence Policy applies.

The post Philippines Vaping Policy Could Be a Model for the Rest of Asia appeared first on Filter.

Globally, 84 percent of smokers now live in low- and middle-income countries, which are also where around 90 percent of tobacco farming takes place. Even in the West, smoking is more prevalent in economically disadvantaged communities. This worldwide class disparity is set to grow. While tobacco use is declining in the West, it continues to increase in LMICs, which are projected to suffer three times the wealthier world’s death toll by 2030.

The impact of tobacco use on the poor is more severe in health and financial terms. The costs of tobacco and associated healthcare strain family budgets and reduce spending in areas like children’s education, pushing smokers and their families further into poverty.

The most favoured tobacco control measure—tax increases—exacerbates the problem. Further stressing poor smokers’ limited resources, it often forces them to switch to cheaper, even more harmful alternatives—for example, the traditional bidis (unprocessed tobacco smoked in rolled leaves) that are far more popular than cigarettes in India.

India loses over 1.3 million lives annually.

Yet keeping taxes on tobacco products used by the poor low is not a better option. This is the case here in India, where almost 80 percent of tobacco tax revenue is from cigarettes—the country has the highest per capita cigarette tax in the world—while bidis are taxed at far lower rates. This incentivises and perpetuates the most harmful tobacco use—dissuading bidi smokers from moving down the harm spectrum by transitioning to cigarettes, while forcing many cigarettes users to pick up deadlier bidis.

The personal suffering of tobacco users who do not have the means nor access to medical care continues to be overlooked in policymaking. In India for instance, only 19 smoking cessation centres exist for a tobacco-using population of about 270 million, while there is no national policy to make telemedicine or other medical support available. Consequently, mortality and morbidity are high: The country loses over 1.3 million lives annually, tobacco-related cancers continue to rise, and rising economic costs drain public finances.

These shortfalls apply globally. Uganda is the only LMIC to have effective monitoring of tobacco use and around 30 percent of LMICs have no tobacco cessation programs, even as they foot the majority of the world’s $1.4 trillion annual costs from tobacco use.

The quit support that does exist is largely limited to services, mainly phone counseling, with questionable efficacy and little reach to poor communities. Further, nicotine gums and patches are unaffordable to most cigarette smokers in India—let alone bidi and khaini users—and there is no movement on subsidizing them, despite their being placed on the essential medicines list by the World Health Organization.  

Why Is Tobacco Use Prevalent in Low-Income Populations? 

Any attempt to honestly tackle this crisis ought to first factor in why poor populations use tobacco in such large numbers. The most cited reason is that they lack adequate information about the harms of tobacco use—but this is increasingly untrue for most parts of the world, as anti-tobacco efforts reach communities across the spectrum. The deeper, more insidious causes highlight the intricate role tobacco plays in such societies.

For people living in poverty, hunger is ubiquitous, and nicotine helps alleviate it for many. Just like the trope of fashion models smoking to stay thin, farm workers in rural India chew tobacco and construction labourers in cities smoke it to suppress appetite, helping them to work longer hours and spend less on food. Poverty also means stress, and nicotine’s calming effect can help there too, as high rates of nicotine use among people with mental health challenges attest.

In rural India, the absence of toilets in many homes means that villagers use tobacco for another practical purpose: to control bowel movements when they go to open areas to defecate. Tobacco-based toothpaste is commonly sold in India for this reason.

In some communities, tobacco is also embedded into cultural identity and rituals.

Other reasons highlighted in research are that many use nicotine as self-medication for ailments they falsely believe it will relieve. And the importance of pleasure in difficult lives should not be underestimated—people may perceive tobacco as a “reward,” one of the few enjoyable things that they can do for themselves. Poor people, struggling with immediate daily challenges, may also feel they have less to lose from future illness and may become more dependent given their dietary and social conditions.

In some communities, tobacco is also embedded into cultural identity and rituals. In the northeast of India, for instance, gifting tobacco during occasions is widespread practice. In villages where tobacco is cultivated, the crop is the focal point of the community. The farmer and his helpers grow and reap the plant, which is traditionally sorted and processed by women at home, while others transport it to markets—each specialization honed over generations. The deep integration of a crop into the social, cultural and economic fabric of farming societies makes simplistic crop-switching initiatives unsuccessful.

These factors run counter to the narrative that the tobacco habit is an extraneous force, demanding simplistic interventions aimed at propping up willpower-backed quit attempts—followed, when such interventions predictably fail, by pinning the blame on communities themselves with overarching terms such as “low desire to quit.”

Until the underlying causes of tobacco use—and the roles nicotine plays in people’s lives—are accepted, understood and addressed, efforts to reduce the tobacco health burden will continue to fail. 

How Tobacco Harm Reduction Can Help 

Efforts to combat malnutrition in India—comprising a holistic view of problems and contributing factors, evidence-led interventions, industry partnership and tailored efforts to modify behavior—created successful public health strategies. There is no reason why these approaches should not be adopted to tackle the tobacco crisis.

In this context, especially with high tobacco use, lack of motivating factors to quit and inadequate support, it is vital to consider harm reduction measures.

The onus to address the tobacco epidemic is currently largely on the Indian state. Its resources are stretched between enforcement of supply reduction measures, getting current users to quit and preventing uptake, as well as the somewhat contrasting imperatives of looking out for tobacco farmers and maintaining the state’s foothold in the trade though its investments in tobacco companies and tax revenues.

Tobacco harm reduction measures, if implemented with sensitivity, can help balance the equation.

Encouraging tobacco users to modify behavior, by making lower-risk alternatives available at lower cost, can bring down tobacco-related harms. Most people, regardless of socio-economic status, understand the risks associated with tobacco use and want to protect their health.

An example is the popularity of chaini khaini, a smokeless product falsely marketed in India as snus and carrying a higher risk profile. Many people have nonetheless switched to it in the belief that it is safer. If genuinely risk-reduced alternatives were accessible, affordable and perhaps incentivized, a rapid lowering of population-level harm would be achievable without drawing heavily on the state’s resources.

It is a widely held belief that harm reduction alternatives are expensive … This view overlooks the ingenuity of people in LMICs.

The harm reduction approach factors in the various integrations of tobacco and nicotine into people’s lives, instead of focusing entirely on severing these links. It is also sensitive to the situation of farmers, providing alternatives to preserve their livelihoods. One way to do this is to develop supply chains for the various other uses of tobacco, from making of cardiac drugs, oil to protein powder, which I learnt about while visiting the state-funded Central Tobacco Research Institute in southern India.

It is a widely held belief that harm reduction alternatives are expensive—that being technology- and research-intensive, it is difficult to make them available below certain price thresholds. This view overlooks the ingenuity of people in LMICs and how other tech resources—from mobile phones to patented medicines—have been adapted and widely adopted.

In a project to evaluate the efficacy and affordability of vaping for India’s bidi users, supported by Knowledge-Action-Change, I found positive outcomes for both, if adequate modifications are made. It turns out that even at current prices, vaping devices and appropriately flavoured e-liquids (India is a major producer of liquid nicotine) are within the reach of bidi smokers. Another project in the same vein found that lower-risk snus can be made locally at price points khaini users can afford. If state support though tax incentives is applied, these lifesaving options can be produced and distributed at scale. 

The Road Ahead 

Despite the urgent need, and the availability of solutions, India appears determined to shun the strategy of tobacco harm reduction. In late 2019 it banned vaping, and there are troubling signs of opposition developing to snus and nicotine pouches.

Just as the bidi/khaini vs cigarette taxation gap ends up incentivizing the former, banning lower-risk products perpetuates deadly forms of tobacco use and eliminates the health benefits and green economic opportunities that a harm reduction model would bring.

Under this model, the government’s control of the tobacco trade, which extends from providing seeds to farmers to partially owning tobacco companies, could even become a force for good because it could directly influence the shift away from deadly products. With even a light touch in the right direction, Indian entrepreneurship, celebrated the world over, could rapidly become engaged in indigenously developing culturally specific tobacco harm reduction solutions, helping improve public health and creating jobs in the process.

What we still lack is the political will to help some of the world’s most vulnerable smokers.

Photographs courtesy of Samrat Chowdhery

Knowledge-Action-Change has provided scholarships to The Influence Foundation, which operates Filter, to support tobacco harm reduction reporting. Both The Influence Foundation and INNCO have received grants from the Foundation for a Smoke-Free World.

The post Can Tobacco Harm Reduction Work for India’s Poor? appeared first on Filter.

This country is now home to an estimated 12 percent of the world’s billion cigarette smokers. Yet even this vast group is only the tip of the iceberg. India has a larger population who smoke local variants of tobacco. These include: bidis, cigarette-like rolls of unprocessed tobacco wrapped in a tendu or temburni leaf; hookah; chilam, a traditional clay pipe; and other forms. Many more people chew tobacco, in forms known as khaini, zarda and gutkha, which avoid some major consequences of smoking, like lung cancer, but still carry significant risks.

Altogether, 29 percent of Indians—about 270 million people, not far off the population of the United States—use tobacco in some form. This figure comprises 42 percent of men and 14 percent of women, making Indians the second largest tobacco-consuming population in the world after China—and given our projected population growth, we could before long take an unwanted lead over our neighbor. We currently bear an enormous health burden of over a million tobacco-related deaths annually, with $22 billion in economic loss.

This massive human tragedy will worsen if we don’t act. But worse still than inaction, the government of India—just recently, more than ever—appears determined to behave in ways that prevent reduction of smoking-related harms.

The first problem is simply a lack of urgency from the Indian state. Although a number of WHO-recommended tobacco control measures have been implemented, and they have led to an absolute reduction in tobacco prevalence of 6 percent over a seven-year period between 2010 and 2017 (according to Global Adult Tobacco Surveys 1 and 2), this is hardly enough. If this fall is not substantially accelerated, it will take almost a century to eliminate tobacco use, in which time many millions more lives will be lost.

India had the lowest quit rates among the countries surveyed in GATS-2 (followed by Indonesia) and though there is an overall decline in use, the disease demography shows tobacco is becoming a bigger killer. Ischemic heart disease and chronic obstructive lung disease, both attributable to tobacco, ranked in positions one and two among causes of death in India in 2016, having ranked sixth and eighth respectively in the 1990s.

At present there are three main lines of state-sanctioned interventions: encouraging cold-turkey quit attempts, cessation services and counseling, and nicotine replacement therapy (NRT). These are not enough. Nationwide quit lines and media outreach have done little to change the 95 percent failure rate of willpower-led cessation. Tobacco cessation clinics remain woefully inadequate, with just 19 functional at present. The effectiveness of NRTs is also limited, hovering near 7 percent.

That favorite measure of policymakers, raising taxes, also has limitations in a country like India with a wide spectrum of popular tobacco products. For instance, raising costs of cigarettes above a certain level forces smokers to shift to cheaper, more harmful variants, thus causing more harm than good. High taxes do little to limit uptake either, when the average cost of loose cigarettes—in practice sold everywhere, although a few states have issued futile bans—is extremely low.

Instead of heralding the public health opportunity THR provides, the influential tobacco control community has put up stiff resistance.

In this environment of non-existent and low-performing interventions, it is important to consider measures that are showing potential elsewhere. Key among them is tobacco harm reduction (THR). This pathway requires only the moderate effort of sensible regulation, with the market and users’ desire for a healthier life doing the rest.

We practice harm reduction all the time in our everyday lives, from switching to safer food habits to driving more eco-friendly cars, and this evidence-based concept is becoming increasingly prevalent in addiction treatment for other drugs.

Electronic Nicotine Delivery Systems (ENDS), such as e-cigarettes, which eliminate the tar produced by combustion of tobacco leaves, have been found to be around 95 percent safer than smoking. Swedish snus, a non-combustible form of tobacco that is placed behind the lip, has been shown by long-term epidemiological studies to also be a greatly risk-reduced alternative.

However, instead of heralding the public health opportunity THR provides, the influential tobacco control community, in India as in much of the world, has put up stiff resistance to its use. This community includes institutions such as the Indian Medical Association, the National Tobacco Control Programme, and the Public Health Foundation of India. There is a high human cost to this “moral” opposition when tobacco use—above all, smoking—is the world’s leading preventable cause of death.

This hardened and evidently anti-people position is a blowback from decades spent fighting the tobacco industry, which undoubtedly has tried all manners of dirty tricks to sell its products, leading to heightened suspicion towards any measure other than total abstinence from nicotine.

However, as with most industries, technology has changed the landscape, which requires a pragmatic recalibration of strategies and an imaginative recognition of opportunities that did not exist before.

In India this opposition has been especially bullheaded. Snus is effectively banned; when companies applied for licenses to produce it, permission was denied because snus is bizarrely classified as a food product, and use of tobacco in any food product is illegal under existing laws.

Then, just last month, the central government issued an advisory to states proposing an outright ban on ENDS. Among the reasons cited were the “harmful” effects of nicotine and fears of teen use. This appears to have be taken out of the old anti-tobacco playbook, but without adjusting for risk-appropriateness and the concept of harm reduction—perhaps because it requires coming to terms with the fact that mitigating harm is a lot more achievable and, therefore beneficial in practice, than being focused on completely eliminating use. Many working in drug addiction treatment (in international contexts, if not so much in the US) jumped this moral hoop long ago, but people in tobacco control, which impacts far more lives in India, unfortunately have not.

For as long as the Indian state’s interests don’t align with those of the Indian people, it falls on the latter to advocate for reason.

There are yet more hurdles. The tobacco industry claims to provide sustenance for 50 million households in India, which includes widespread farming of the cash crop. Add the government’s approximate 30 percent stake in the country’s largest tobacco company, ITC, along with its high dependence on tobacco taxes, and action becomes even more difficult.

It is worth highlighting that ITC’s stock price shot up on the news of the central advisory against ENDS, as investors felt reassured by state action to keep competing alternatives out of the market. (Although ITC has one ENDS product, Eon, its shortcomings and lack of popularity mean the company has no significant foothold in this space.)

Little forward movement on promoting lower-risk alternatives to curb tobacco use is possible until the state can be separated from tobacco commerce. This is a problem which the WHO Framework Convention on Tobacco Control (FCTC) has highlighted—Article 5.3 states, “Parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law”—but not strictly enforced. The most glaring infractions are by the governments of Asian countries with some of the world’s highest rates of tobacco use, and the most urgent need for lower-risk alternatives.

For as long as the Indian state’s interests don’t align with those of the Indian people, it falls on the latter to advocate for reason and workable solutions to our tobacco epidemic. Even those of us who work in this field often feel incredulous that the biggest obstacle to public health remains those who have been tasked to protect it.

Amid these major challenges, the GATS-2 survey estimates that India already has about 260,000 ENDS users. Imagine how many they could become in more favorable conditions—and the corresponding preservation of life and health.

Encouragingly, while the motivation to quit, particularly for low-income groups, is low, there is nonetheless widespread public awareness of the harm caused by tobacco use. India is also a large producer of medicinal nicotine used in e-liquids, which can help in keeping costs down. Experience elsewhere show that adoption of ENDS is highest in lower-income populations because of their cost-effectiveness.

There is thus every reason to believe tobacco harm reduction can become a huge success story in India—if only better, pro-people policies will allow these lifesaving products to become widely available and affordable.

Photo via Palash Jain/Unsplash

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