The pandemic served as a wake-up call for enterprises all over the world, as well as nations, to stand up and recognise what is required to mitigate the risks of another global shock. Without a doubt, among the countless diseases and ailments, there are those that we can control, and one of them is substance abuse.
It is possible to start with harm reduction to attain success from substance usage. Furthermore, one part of harm reduction is to comprehend the fundamental issues that customers experience. Dr. Kiran Melkote, an orthopaedic surgeon in Delhi and a member of AHRER (Association for Harm Reduction, Education, and Research), provides an in-depth analysis of current evidence-based tobacco harm reduction techniques, the challenges of quitting cold turkey, and strategies to achieve a 30 percent reduction in tobacco use by 2030.
Tobacco harm reduction – how consumers could secure the greatest public health win of the 21st Century?
Tobacco consumption remains a huge public health problem worldwide, causing over 8 million deaths annually – 1.35 million in India alone. But for every person who dies from tobacco use, over 30 live with tobacco-related illnesses which adds to the invisible toll of tobacco not captured by death rates.
Quitting tobacco is not easy for everyone and tobacco dependence is a very real entity. Most Tobacco control strategies focus more on counselling and support with very little done to address the dependence aspect. Understandably, the quit rates are terrible – less than 0.5% in India annually as per the GATS 2 data.
Tobacco harm reduction or THR can step in and address the needs of those who want to quit tobacco but are unable to, as well as those who are unwilling to quit tobacco – they could be transitioned to less harmful or reduced risk products to mitigate the harm caused by tobacco. Will saving lives and reducing disease from tobacco be a spectacular win for public health in the 21st century? Most certainly.
Could you share with us what are some of the leading challenges consumers struggling with addiction face today, in the context of determining whether to quit cold turkey or to find a safer alternative?
According to the CDC USA, about 70% of all smokers want to quit smoking but less than 7% manage to quit. Indian figures from the GATS 2 are worse: 8.1 million quit over 7 years – less than 0.5% of Indian tobacco users annually. A Canada based study found that it may take over 30 attempts for most smokers to quit and the chance of quitting diminishes with each attempt.
We have nearly 8 billion people on earth and presumably, each individual is different. Why then, do we persist with the fantasy that one method can work for each and every person? Quitting cold turkey or quitting tobacco completely is a noble goal that each tobacco user should aspire to, but in the real world, when quit rates are so low and relapses are high – is it correct to write off the people who can’t or won’t quit?
I truly believe that one must try to quit tobacco completely. But in case we can’t (just like 99.5% of our tobacco users) then what? Should it be a crime to use a less dangerous product to save our lives?
Do you think the harm reduction approach is evidence-based? Is there adequate application of harm reduction principles in clinical practice in your view?
Harm reduction approaches have been used successfully in public health programmes for Illicit drug use, reduction of drunk driving, sex education and HIV prevention etc. and these are well established and proven strategies worldwide and even endorsed by the WHO. These programmes have positively impacted peoples’ lives and helped reduce the burden of death and disease and even brought down crime rates.
Tobacco harm reduction extends the principles of harm reduction to tobacco – mitigating the risks of tobacco by transitioning people to reduced risk products. The option for total abstinence is one of many offered to tobacco users.
On the tobacco harm spectrum, beedis and cigarettes remain the most dangerous followed by our smokeless tobacco or SLTs like Khaini, Ghutka etc. Reduced risk products including Swedish snus, heated tobacco products and Nicotine Replacement Therapies (NRTs) like nicotine pouches, vaping / e-cigarettes, nicotine gums, lozenges, patches etc fall at the other end of the spectrum. Switching from a more harmful to a less harmful product is not going to be as great as quitting completely, but it is definitely a million times better than continuing to use the more harmful product.
How can we better sensitize both lawmakers and the lay public to the benefits of switching to less harmful alternatives?
As a part of AHRER (Association for Harm Reduction Education and Research), we are constantly involved in disseminating the benefits of harm reduction – to our doctors and healthcare professionals, our policymakers and the general public. There are a lot of myths around, helped in a big way by the ideological stance taken by the WHO against tobacco harm reduction – a stance that ignores the scientific evidence in favour of tobacco harm reduction in general and vaping / e-cigarettes in particular. Our country passed laws in September 2019 to ban commerce in e-cigarettes and vaping devices and this has unfortunately driven the business underground where it has escaped regulation and oversight.
The way forward is to educate ourselves about harm reduction and cultivate a scientific temper where we avoid biases and question dogmatic statements made by our policymakers or even the WHO. The pandemic has shown us that even the WHO makes mistakes and critiques and debates are needed more than ever.
Which countries have set the benchmark, when it comes to creating sustainable and scalable harm reduction frameworks in your view?
The UK, where vaping is an important tool in quitting tobacco and is prescribed by NHS hospitals and endorsed by respected institutions like the RCP (The Royal College of Physicians) and PHE (Public Health, England) and even included in the NICE guidelines (National Institute of Health and Care Excellence) would be the best example. Smoking rates have plummeted following this strategy and there are no trends to suggest increased underage vaping or vaping as a gateway to cigarettes – the evidence suggests that vaping is a gateway OUT of cigarette use.
Other countries too have made significant strides in adopting harm reduction including New Zealand, The Philippines, Germany, Russia, Canada, Sweden, UAE, Japan etc.
Why is there a need for robust public health policy to address tobacco in India?
In spite of the money and effort spent on tobacco control, our death and disease rates remain unacceptably high. The quit rates in our country are among the lowest in the world. Clearly, we need a re-think of our methods if we are to learn and improve. Basing policy on science needs to be the first step and harm reduction is an essential strategy we can no longer afford to ignore.
India’s goal is to reduce tobacco usage by 30% by 2030. What role can harm reduction play in addressing India’s tobacco goals?
The WHO global action plan on tobacco calls for a 30% relative reduction in tobacco use prevalence compared to 2010 levels. In real terms, this is a 7% reduction and since 30% sounds so much better than 7%, we choose the relative reduction over absolute reduction goals. This is called framing.
The difference is enormous. 30% absolute reduction would translate into helping over 82 million tobacco-users while 30% relative reduction aims to help an underwhelming 19 million.
If we adopt harm reduction in a meaningful way, 30% absolute reduction would be a realistic goal for our country. Especially considering the pattern of tobacco use – here we have nearly 200 million SLT users and 72 million beedi users with about 28 million cigarette users – efforts so far are focussed on the cigarette smokers to the exclusion of the larger majority who smoke beedis and use SLTs. The SLT users can be especially receptive to harm reduction measures in the form of oral nicotine replacements and we can reap huge benefits by broadening our focus and harnessing tobacco harm reduction.