‘Nicotine addiction hasn't disappeared, it has simply shape-shifted'

Indian Express

5 days ago

Smokeless tobacco is the number one problem in India and there is an urgent need to strengthen laws and regulations to address it effectively,' Dr Shalini Singh, director of the Indian Council of Medical Research-National Institute of Cancer Prevention (ICMR-NICPR) and the World Health Organisation-Framework Convention on Tobacco Control (WHO-FCTC) Global Knowledge Hub on Smokeless Tobacco told The Indian Express.
On the sidelines of the World Conference of Tobacco Control under way at Dublin, Dr Singh observed that globally, cigarette smoking is on the decline — especially in high-income countries, where public health regulations have tightened and consumer behavior is shifting.
'But nicotine addiction hasn't disappeared; it has simply shape-shifted. The rise of electronic nicotine delivery systems (ENDS), synthetic nicotine pouches, and 'flavoured wellness' lozenges represents a quiet but aggressive reinvention of the nicotine business. These products are marketed as cleaner, safer, and even medicinal — often using the language of 'harm reduction'. While India has banned e-cigarettes, these new delivery systems pose a serious public health risk in countries with poor implementation of regulations,' Dr Singh said.
India is already home to one of the largest populations of smokeless tobacco (SLT) and bidi users globally. According to the Global Adult Tobacco Survey (GATS) 2016–17, over 199 million Indians use SLT, 72 million smoke bidis, whereas only 37 million smoke cigarettes. Less than 4 per cent of tobacco users use any cessation pharmacotherapy, and over 70 per cent quit without formal help. 'This makes India an especially vulnerable target for the tobacco industry's new nicotine expansion strategy,' Dr Singh said.
Harm reduction, when implemented as part of a comprehensive cessation strategy, has clinical value. But the tobacco industry has co-opted the term 'harm reduction' to further its own interests of reduced regulation and to expand its user base. While India banned e-cigarettes in 2019 under the Prohibition of Electronic Cigarettes Act, experts said the same industry has repackaged nicotine in non-combustible, e-cigarettes adjacent forms — such as synthetic nicotine pouches and gums — often marketed as herbal, Ayurvedic, or wellness products on Indian e-commerce platforms. 'This represents not only a strategic circumvention of the e-cigarette ban but also a continuation of the industry's practice of promoting products that protect profits while presenting a facade of supporting smoking cessation,' Dr Singh added.
India permits over-the-counter (OTC) sale of 2 mg nicotine gums and lozenges, based on the assumption that easier accessibility would enhance tobacco cessation efforts. The 2 mg NRT formulation, particularly when used with behavioural counselling, can play a crucial role in reducing dependence on smoking tobacco. Global evidence is clear: NRTs are most effective when used with structured counselling and support, not when taken in isolation. Many low- and middle-income countries (LMICs), including India, have NRTs in OTC markets and require integration with comprehensive cessation services. In India, the effectiveness of OTC NRT is further undermined by systemic challenges: the very low cost of smokeless tobacco (SLT) products like gutkha, khaini, and bidis; the online sales of nicotine products frequently bypass age restrictions;and the economic burden of NRT — where one week's supply often costs more than a month's worth of SLT or bidi. Without counselling support and affordability measures, OTC NRT risks becoming another market commodity rather than a true cessation aid,' Dr Singh pointed out. Long-term use of nicotine — whether through vaping, pouches, or even unsupervised NRT — poses real risks. Yet, these products are increasingly available through online platforms in India, marketed with no warning labels, no age-gating, and no evidence-based cessation claims, Dr Singh cautioned.
Urgent policy priorities include banning of flavoured and industry-manufactured non-combustible nicotine products, including gums and pouches not intended for supervised cessation. There is a need to tightly regulate OTC NRT, especially in flavours and formulations attractive to youth; regulate all online sales of nicotine products with mandatory age verification, licensing, and product labelling.