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Experts contradict ICMR white paper on ENDS to tackle tobacco related cancers

Our Bureau, Mumbai
Tuesday, August 20, 2019, 17:00 Hrs  [IST]

Experts from India have contradicted Indian Council of Medical Research (ICMR)'s white paper on electronic nicotine delivery systems (ENDS) saying that it fails to present a balanced overview of the risk-benefit ratio of ENDS vis-Evis other cancer causing combustible tobacco products.

The experts state that ICMR paper presents a selective review of literature and fails to consider the substantial evidence that demonstrates the harm reduction potential of e-cigarettes.

Most credible international institutes maintain that e-cigarettes are at least 95 per cent less harmful than tobacco cigarettes. This calculation is based on the much lower toxic emissions of e-cigarettes.

Experts have written to the Director General of the ICMR claiming that the ICMR White Paper published on May 31, 2019 which recommends e-cigarette ban is not justified.

The letter, signed by experts from 20 countries, including India, urges ICMR to reconsider its recommendation of banning e-cigarettes.

The letter also draws upon the findings of an elaborate Critical Appraisal of the Scientific Evidence cited in the ICMR White Paper. It challenges ICMR radical recommendation of complete prohibition on ENDS or e-cigarettes, claiming that these views are in contradiction of the broad consensus amongst the scientific community.

The Critical Appraisal systematically reviews the four key arguments made by ICMR and presents evidence to counter them.

The Critical Appraisal has been co-authored by renowned global experts Konstantinos Farsalinos of National School of Public Health, Greece, Riccardo Polosa of the Department of Clinical and Experimental Medicine, University of Catania, Italy, and Dr. Atul Ambekar of the All India Institute of Medical Sciences (AIIMS), New Delhi and Chairperson of the Addictive Disorder Specialty Section, Indian Psychiatric Society.

One of the major contentions of ICMR white paper was the lack of long-term evidence. However, it is accepted practice, even among pharmaceutical products, to rely on post-marketing surveillance to examine long-term health effects, as it is unviable for any product to be marketed only after decades of research.

As per the evidence highlighted in critical review, more than 99.9% of e-cigarette emissions from exhaled breath of vapers consist of the base ingredients (propylene glycol, vegetable glycerol), water and nicotine, contrary to ICMR position. In addition, unlike in cigarette smoke, side-stream emissions are absent in e-cigarettes and the only environmental exposure is from diluted aerosol exhaled by users.

Additional evidence cited in the Critical Appraisal shows a positive association between e-cigarette use and smoking cessation or reduction. An analysis of a large US population survey indicated that the substantial increase in e-cigarette use between 2010 and 2015 was significantly associated with the first significant increase in smoking cessation in the past 25 years.

ICMR criticism of sustained use of e-cigarettes by people who managed to quit smoking is in direct contradiction of the stance taken by the US FDA and UK MHRA, which recommend the long-term use of nicotine in the form of alternatives if needed, to maintain smoking cessation, prevent relapse, or even to reduce smoking. Studies have shown that risks from long-term nicotine intake are minimal and by far outweigh the benefits of smoking cessation.

ICMR paper claims that e-cigarettes are used by the youth as a gateway to smoking and nicotine addiction citing the 2016 US Surgeon General report. However, the Critical Appraisal shows that the US Surgeon General report does not differentiate between ever-use (even once), experimental use (in the past month) and regular use. The experts present evidence from the USEMonitoring the Future and National Youth Tobacco Survey, which shows that frequent e-cigarette use is confined almost completely to smoking youth and rate of use among never-smokers is low. The issue of addiction to nicotine from e-cigarettes, therefore, is irrelevant since its users were already addicted to nicotine from tobacco cigarettes.

According to the experts, ENDS offer an opportunity to improve public health and they fear that this opportunity will be lost if ENDS are banned in the country.

Farsalinos, Polosa, and Ambekar draw attention to the regulatory framework for e-cigarettes in the European Union and Canada and urge that India combat its huge tobacco challenge by including tobacco harm reduction in its tobacco control strategy and frame regulations on similar lines.


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