The ban on e-cigarettes in India has faced controversy from multiple sources, ranging from the industry itself to some health experts. However, recent scientific data, as well as the opinion of leading European cardiologists, may vindicate the government’s position on the matter.
Professor Thomas Münzel, of the Department of Cardiology of the University Medical Centre Mainz in Mainz, Germany, led a recent study into the effects of e-cigarettes on health. He praised the decisions of countries such as India, Brazil, Singapore, Mexico and Thailand to ban the devices, stating that e-cigarettes are dangerous and addictive to the extent that more countries should consider a ban in these countries’ stead.
“We need to focus on the youth because this is by far the largest market,” Münzel said. He pointed to research by the US Centers for Disease Control and Prevention, which found that “over 3.6 million children in the US use e-cigarettes, with a jump of 78 percent, from 11.7 percent to 20.8 percent, among US high school students reporting e-cigarette use from 2017 to 2018.”
Münzel referenced the notion that e-cigarette use was intended to act as a cessation tool for tobacco users. “Vaping, which was actually intended as an aid to help smokers quit, developed into a trend among young people in the US, leading to nicotine addiction, even among those who had not smoked before,” he said. This echoes previous assertions by Indian government figures in support of the e-cigarette ban. Union Finance Minister Nirmala Sitharaman, when announcing the Centre’s e-cigarette ban in September, said “e-cigarettes were promoted as a way to get people out of their smoking habits but reports have shown that many people are not using it as weaning mechanism but are addicted to it.”
The study led by Münzel is, admittedly, rather small scale. The tests were conducted on twenty individuals who were known cigarette smokers (though did not use e-cigarettes) before results were again tested by exposing 151 mice to e-cigarette vapour over one, three or five days for twenty minutes six times a day. The research investigated the effect of e-cigarette vapour on blood flow in the brachial artery in the upper arm of the individuals before they vaped an e-cigarette and then fifteen minutes afterwards.
The results concluded that just one vaping episode increased heart rates and caused the arteries to stiffen and the inner lining of the arteries — the endothelium — to stop working properly in the smokers. The endothelium is responsible for maintaining the correct dilation of blood vessels. It also helps in regulating inflammation, making the tissue important in the body’s response to both infection and toxic substances. Endothelial dysfunction is involved in the development of cardiovascular disease.
Results from the mice allowed for a more in-depth biochemical analysis. It was found that a toxic chemical called acrolein, which is produced when the liquid in e-cigarettes is vaporised, activated an enzyme within the bloodstream called NOX-2. NOX-2 is involved in both the body’s defences against invading pathogens, as well as in a process called oxidative stress – an imbalance between free radicals and antioxidants in the body.
This resultant oxidative stress — and, therefore, inflammation — as a result of the activation of the enzyme, was found to be responsible for the damage to the endothelium. Critically, the inflammatory effects were found to be present across the cardiac system, including within the blood vessels present in the brain. This could have severe consequences to human health over a longer period of time.
Of particular concern, then, is the use of e-cigarettes by children. The inflammatory effect, prolonged over an extended duration in an individual whose body is still developing, could have untold effects on long-term health, potentially causing dysfunction within brain and cardiac system development.
“Our data may indicate that e-cigarettes are not a healthy alternative to traditional cigarettes, and their perceived ‘safety’ is not warranted. In addition, we still have no experience about the health side effects of e-cigarettes arising from long-term use,” warned Professor Münzel. “Research like ours should serve as a warning about their dangers, and aggressive steps should be taken to protect our children from health risks caused by e-cigarettes.”
Despite results indicating the dangers of e-cigarettes, criticism of the decision to ban e-cigarettes has been abundant in the months since the decision was passed. The cited reason behind the ban was the prevalence of the habit among children. Indeed while cigarette usage has overall fallen in India, studies show that younger males have actually taken up the habit in higher numbers. It was feared, therefore, that e-cigarettes would act as a gateway to tobacco usage in children, teenagers and young adults.
Some experts disputed this claim, arguing that the devices actually reduce the rate of smoking by acting as a nicotine cessation device, in which a person can gradually wean themselves off from nicotine addiction. However, the government responded with claims that many individuals are not using e-cigarettes as a means to stop smoking, but are in fact addicted to the e-cigarettes themselves, an argument supported by Professor Münzel.
E-cigarettes occupy a unique position in that many of their major selling points appeal directly to a younger audience — many of these being factors that are either non-existent or to a lesser extent in tobacco smoking. These include the use of fruit-flavoured vaping liquid, or the prevalence of vaping “tricks” such as blowing smoke rings seen on social media.
A key argument against the ban was that a demand for the product clearly exists. Due to this, a ban on the products would simply drive them underground and create a thriving black market. Such concerns were strongly expressed in India.
“The reality is, and everyone knows this, that blanket bans don’t work,” Praveen Rikhy, convener of the Trade Representatives of ENDS [electronic nicotine delivery systems] in India, commented earlier this year. “All such prohibitory orders succeed in doing is pushing the products underground, giving rise to a flourishing ‘grey’ market, in which the unscrupulous dealers are the king and the customers are forced to consume sub-standard and spurious products, at exorbitant prices.”
This concept is perhaps best illustrated by India’s alcohol-free states. These areas see frequent outbreaks of acute alcohol poisoning, or lethal effects related to contaminants found in the alcohol that in many instances reach death tolls numbering close to, or in excess of, 100 individuals. As there is no longer any regulation on bootleg alcohol, dangerous additives are often found, with authorities only being notified after deaths occur.
An unregulated black market could potentially be more dangerous than if e-cigarettes were sold legally. Therefore, if India is to truly curb usage of the devices, the ban must be enforced or replaced with strict regulation to prevent their sale and advertising to minors. As Professor Münzel notes, the long term effects of vaping are a complete unknown, for them to be marketed as a healthier alternative to smoking is presumptive. More research into the effects of the devices, therefore, is a necessity.
“We cannot allow an entire generation to become addicted to nicotine,” he asserts.
