Samrat Chowdhery is the director and founder of Association of Vapers India – AVI and Council for Harm Reduced Alternatives -CHRA. These organizations have been advocating for risk reduction in tobacco use since 2016, and most importantly, campaigning for access to less harmful alternatives such as vaping, snus, and Heat not Burn in order to help reduce the high risk of tobacco burden in India.
He is currently the President of the International Network of Nicotine Consumer Organization – INCCO.
CASA – Your take on nicotine and its role in cessation?
SAMRAT – This question is best answered by a medical expert, but what I can say is that I see NRTs (gums, lozenges, patches etc.) which contain nicotine as approved therapy for cessation. This should mean that the role of nicotine is well-established and accepted. The WHO has put out guidelines that NRTs be included in the list of essential medicines. Besides, in my view, the focus should be on preventing 8 million tobacco deaths every year than on nicotine which though it causes dependence, isn’t what kills.
CASA – What would you say to those that oppose the inclusion of Vaping, Snus/Nicotine Pouches and heating products in the fight against smoking?
SAMRAT – To a degree I understand where they are coming from. For decades they fought the tobacco industry which lied and made outright false claims to fool the public and the academia. When they could not, they employed dirty tricks to discredit and create confusion. They kept making cosmetic changes to cigarettes and presenting them as safer, which took decades of research to negate, by which time the perception of safety had been well and truly sold to the public… for instance the mild cigarette. These tricks had the cumulative effect of hardening the position of tobacco control, to an extent where they decided that the tobacco industry cannot be a part of the solution and must be done away with entirely. In 2003, a global treaty was signed which put a target on the back of the industry and Article 5.3 was enshrined.
But then things changed with invention of safer alternatives. Technology has reshaped every part of our life, so what were the chances innovation won’t happen in tobacco or nicotine products. The big change of course was the decoupling of tobacco from nicotine. Now the situation changed, drastically. But the tobacco control has so far failed to adapt to this new reality.
CASA – What is harm reduction? And why is it a necessary approach for Low Medium Income Countries?
SAMRAT – Harm reduction applies to all spheres of our lives. Let me touch upon a few. At an individual level, harm reduction is a natural, intuitive response when dealing with risk. For instance, when riding a bike and realizing the attendant dangers, the natural response is to wear a helmet not to stop riding, or to use less harmful food products than giving up their use altogether. It is a self-preservation response.
At the policy level, it is about focusing on controlling the harmful effects of a risky action than the action itself. A recent example is the ongoing pandemic response. Many nations initially responded with hard lockdowns, but that has serious consequences. then realized it’s better to have harm reduction measures such as wearing masks and social distances which allow people and economy to function. In AIDS and addiction treatment too, the benefits of harm reduction are well-established. But these had to be fought for, over decades. It is in tobacco control, perhaps the biggest battle of because the number of lives it touches, there is still resistance.
Much of medicine is harm reduction too as it is focused on treatment, which is controlling the ailment and relapse. In LMICs, in the context of tobacco harm reduction, harm reduction policies are important because they take the load off the government machinery in improving public health, giving individuals the choice to make safer decisions. Instead of creating and enforcing an environment of prohibition, they should create an environment where an individual is encouraged to make less risky decisions.
CASA – Why are safer nicotine products like Snus / E-cigarettes necessary in the fight against smoking?
SAMRAT – To understand this one has to look at why people smoke and how they can be made to stop. There are over a billion people today who smoke or use tobacco products and they started and continue to use for different reasons, which range from cultural to social to economic. Many of them have tried to quit, most through cold turkey and some with NRTs, but failed. Most understand that smoking is a risky habit, yet can’t get out of it. Then there are some who don’t want to quit for various reasons.
So when there is such variance in tobacco use characteristics, can the policy response be single- mindedly focused on elimination of tobacco use, or would it be better to focus on ensuring people don’t die from it? Currently there are limited options for smokers to quit – cold turkey doesn’t work that well, NRTs improve the chances but slightly, behavioral support is good but its available to a few. We should be expanding the number of ways people can quit, and that is where snus and e-cigarettes come in. They present a humane solution to a problem which cannot entirely be solved by hard measures.
CASA – Isn’t vaping a bit too expensive for smokers in Africa? If so, what would you recommend?
SAMRAT – Like any other technology, vaping will get cheaper and cheaper over time. Cellphones when they first came were unaffordable to most, but now are accessible to almost everyone. It is true that vaping has so far been targeted as the middle and upper segment, because that is where the profit margins are. But as global use increases, prices will come down. That said, even now vaping is quite cheap at the lower end, and can be made cheaper if local industries got involved. This vape pen costs a dollar if you buy in small bulk, liquids (and Africa has significant local farming of tobacco) can be made quite cheap too. By the way, I gave up smoking with this pen 7-8 years ago, it was expensive then, about 50 dollars.
CASA – Is Snus/Nicotine pouches a viable alternative for smokers in the African region, considering affordability and less stringent regulations?
SAMRAT – Any harm reduction method that helps smokers and tobacco users quit is to be welcomed. And different things for work different people and across different regions. We know that snus is a great quit method from Sweden, where it is most used, having the lowest smoking rate in Europe. But smoking also has a strong behavioral aspect, the hand to mouth movement, the inhalation, which many users find difficult to get out of and that is why vaping has had such rapid success among smokers. Hence snus may not work for everybody. But if the regulatory environment favors it, then that is a good place to start. It also depends on which product the industry takes a liking to, and their decisions are going to be cold ones, profit, availability of raw materials, supply chain, regulatory environment etc. Also worth keeping in mind the economics of it – smoking generates lots of profit and tax, hence whether we like it or not, the tilt always seems to be towards less effective means to quit… look at NRTs. Hence snus might find better favor with authorities.
CASA – Should safer nicotine products be classified under Pharmaceutical products or consumer products?
SAMRAT – Personally to me it does not matter who grabs the THR pie, pharma or tobacco or another industry. What is important is that we can ensure wide access, at price points people can afford and suitable variations that people can adapt to their specific needs. These goals I feel are best achieved the consumer products route since medicalization means huge investment in developing products and getting approvals, this means consumers pay more, and have access to smaller variety of products, and there is concern that medicalization will do to vaping what it did to NRTs, which basically make them ineffective. If the medicalized products can be made cheap, widely available, have shortened development to market cycles (because this is a highly innovative segment), don’t kill innovation, then why not? It also depends on which country and what its framework is, there are different regulatory approaches possible, perhaps even a combination of the two where certain aspect, lets say nicotine, is pharma led and product development is not.
One last thing is that smokers don’t see themselves as ill or requiring medical support, so medicalized products will face a barrier. Quitting should be easy, easily accessible, and importantly, enjoyable.
CASA – One of the challenges we face here is lack of understanding of harm reduction and safer nicotine products. What can be done to change that?
SAMRAT – I invite you to look at things a bit differently. What you consider a challenge, and it well is, is also an opportunity. If you see what is happening in the west, in the UK for example, which is the most pro-vaping country in the world, also the US which has the highest number of vapers, the perception of vaping among smokers is still largely negative and its getting worse by the day. Here you have an opportunity to seize the narrative before minds get vitiated against THR products and tell people about the science and empirical evidence backing these alternatives. For this you could hold more public facing initiatives to spread awareness, have routine dialogue with the media and also develop a unified African voice for tobacco alternatives. You have the freedom to be proactive now, later you will have to be reactive.
You can follow Samrat Chowdhery and CASA on Twitter @SamratTHR and @GoingSmokefree respectively.
