Tobacco Endgame: Can India Share the Dream?

Tobacco use is a global public health concern and the leading cause of preventable morbidity and mortality today. ¹ Even though more than 80% of the world’s tobacco users reside in developing countries, tobacco control is a prerogative for developed countries as well.^{1, 2} Over the last 40 years, New Zealand, a nation where tobacco use dates back to ancient history, emerged as a world leader in tobacco control. ³ With bans on tobacco advertising, the creation of tobacco-free spaces, and targeted initiatives for the prevention of early smoking initiation, New Zealand witnessed an almost consistent fall in the prevalence of tobacco use since 1975 and became the country with one of the lowest prevalence of smoking among developed countries in the 1990s. Smoking prevalence among the 25–45 years age group went as low as 18% in 2018 and 4.6% in 2021. ⁴ Most of the efforts to reduce smoking were directed toward demand reduction. With a radical shift in philosophy from reduction to elimination, New Zealand announced an updated “Smokefree New Zealand 2025” plan in January 2022, which aimed to reduce smoking prevalence to less than 5% by 2025. A key element of this plan is a “smoke-free generation,” ⁵ meaning anyone born on or after January 1, 2009, would be banned from ever buying tobacco products.^{1, 2} Other measures include steadily increasing the permitted age for procuring tobacco products legally, reducing the legal amount of nicotine in tobacco products available commercially, cutting down the shops where cigarettes could legally be sold, and increasing funding for addiction services. ⁶ The New Zealand government estimates saving NZ$5.25 billion in health expenditure by that time. An added sum of NZ$36.6 million has been set aside to be utilized over four years for the scale-up of smoking cessation services in the country. ⁷

The Good, Bad, and Ugly

This generational fade-out policy has been a topic for debate since its announcement, with experts examining its implications from various perspectives. The plan incorporates both demand and supply reduction measures but imposes no restrictions on Electronic Nicotine Delivery Systems, indicating an encouraging attitude toward the harm reduction paradigm for tobacco use.^{2, 8} Reduction in the legally permissible amount of nicotine in commercially available tobacco products may serve as another harm-reduction strategy for those already dependent on tobacco. It may provide a lesser intense high to naïve tobacco users, thus reducing the chances of continued tobacco use resulting in maladaptive patterns. The proponents of the plan concur that it is feasible and terms of implementation and the targets are realistic and achievable. ⁹ On the other hand, critics and experts in Addiction Medicine warn that the ban could backfire disastrously, making cigarettes the glamorous “forbidden fruit.” It may also directly result in a flourishing black market for tobacco and, much like the Prohibition Era for alcohol, further pressurize the criminal justice system, besides cutting down on the revenue that was earlier generated by regulated tobacco sales. ² Another public health risk is related to the removal of checks on the quality and safety standards of tobacco products which may be compromised once the tobacco industry falls out of the purview of the government authorities as a result of the ban. Reduction in nicotine content of tobacco products may also increase the risk of a compensatory increase in consumption of these tobacco products, and employment of other harmful methods of use (covering cigarette filters, taking longer drags, reverse smoking, etc.) in order to obtain the required nicotine dose. Others have expressed concerns about the plan as an attack on personal freedom, a risk of putting small retailers out of business and discriminatory nature, as a Smokefree Generation will mean that for a number of initial years, some New Zealand adults will be able to procure tobacco products while other, slightly younger adults will be legally banned. ¹⁰ Most of these claims and opinions are based on past experiences, and a lot of the impact of this new plan still remains to be seen.

Following Suit

The Smokefree New Zealand 2025 plan is one of the first implementations of the tobacco “endgame” concept, which suggests moving beyond tobacco control and entails the continued presence of tobacco as an ordinary consumer product towards a tobacco-free future wherein commercial tobacco products would be phased out or their use and availability significantly restricted. Following New Zealand’s example, on February 17, 2022, Malaysia announced its plan to introduce a similar generational ban on legally purchasing tobacco products for anyone born after 2005. ¹¹ Less than a month later, Denmark announced its own plan to ban the sale of cigarettes and other nicotine products to anyone born after 2010. ¹²

This may remind us of Singapore as one of the first nations to ban smoking in public places in the 1990s. Singapore’s ban was widely criticized at the time of its introduction but was emulated worldwide within the next few years. ² Today most ASEAN (Association of Southeast Asian Nations) countries have imposed bans on the sale of tobacco products to minors in accordance with the WHO Framework Convention for Tobacco Control (FCTC), 2003. However, these regions continue to house 34% of the world’s tobacco users in the 13–15 years age group. ⁴ This begs the question: Is the generational tobacco ban and fade-out approach the next step in tobacco control for South East Asia?

Easier Said Than Done

This question may not apply with equal importance to the whole of South East Asia due to wide variability in the burden and pattern of tobacco use, economics, governance, feasibility, and acceptance by different countries, which have unique nuances to this multifaceted issue, different levels of tolerance towards the problem and their own specific policies and laws in place (13).

Thus, let us consider a single Southeast Asian Nation, India, for further discussion. Akin to the rest of the world, tobacco use is a public health concern in India. Currently, 28.6% of all adults consume tobacco, either in smoked or smokeless form, including 42.4% of men and 14.2% of women. ¹⁴ For adolescents, current tobacco use prevalence is 19% for males and 8% for females. ¹⁵ More than 1 million adults die each year in India due to tobacco use accounting for 9.5% of overall deaths. Tobacco use contributed to nearly 6% of Disability Adjusted Life Years until 2016. The total economic costs attributed to tobacco use from all diseases in India in 2017–2018 for persons aged 35 years and above amounted to INR 177,341 crores (USD 27.5 billion). ¹⁶ Nearly half of the tobacco users consume locally-made hand-rolled cigarettes called beedi. Smokeless tobacco, also popular, is used by one in four adults. Half of the adults and 27% of adolescents aged 13–15 years are exposed to second-hand smoke at home; 29% of adults and 40% of youth are exposed to it in public places. ¹⁷ India became a party to the WHO FCTC in 2005. The primary national tobacco control law is the Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply, and Distribution) Act, 2003 (COTPA), which prohibits smoking in all public places, including schools, hospitals, and workplaces; prohibits most forms of tobacco advertisement, promotion, and sponsorship; and mandates pictorial and written health warnings on individual packaging. ¹⁷ Despite the existence of these evidence-based practices as laws for many years, the burden of tobacco use continues to remain high in India.

Considering the applicability of a generational tobacco ban in India, one is faced with a multitude of questions. Several points need to be considered even before feasibility is discussed. Will such a ban effectively reduce the prevalence of tobacco use in a country like India? Research is conclusive on the fact that delayed initiation of a substance is an effective way of reducing the risk of dependence and mitigating the psychosocial adversities associated with early onset substance use.^{18, 19} Reducing the availability of tobacco products at a young age, which is often characterized by experimentation and novelty seeking, may temporarily deter youth and delay tobacco use initiation, reducing its long-term adverse consequences. ¹⁸ Recent qualitative studies from New Zealand reported a welcoming response from participants toward the new policy. They recommended that the focus be shifted to supply reduction measures for tobacco elimination, indicating mass appeal and acceptability.^{20, 21, 22}

Considering the feasibility of a generational fade-out plan, one is faced with multiple sociocultural challenges. Epidemiological studies have reported the practice of smoking beedi (indigenous, hand-rolled cigarette, tobacco flakes rolled in a leaf) in a large majority of South East Asian smokers, a market that continues largely unregulated in India. ²³ Beedi is also known to have greater risks to health than cigarettes due to higher concentrations of tar and other carcinogens. ²⁴ Making commercially available tobacco products inaccessible to a generation may push them towards using the cheaper, locally-made beedi, a much riskier alternative that is practically impossible to control in terms of trade, quality, and compliance with the law. The situation is further complicated by the common practice of using tobacco in social groups, where sharing is common, and the age difference is not a barrier of significance. The discriminatory nature of the Tobacco-free Generation plan, based on year of birth, stands to be rendered completely useless in a situation like this, where an older companion may easily procure tobacco products in lieu.

India prohibited the sale of tobacco products to anyone less than 18 years of age in 2003, with fine and imprisonment imposed as penalties for related offences. ¹⁷ However, research indicates continued high neighborhood access to tobacco products for adolescents in both rural and urban India.^{25, 26} This is corroborated by the prevalent use of tobacco products among adolescents, with an average age of initiation of tobacco as 11–12 years; it is evident that prohibition-based laws can be easily ignored.^{19, 27}

Epidemiological data for the use of cannabis and other illicit substances also supports the existence of the “forbidden fruit phenomenon,” where criminalizing a substance made it even more tantalizing to the curious. ²⁸ After banning access to a substance altogether, it does not take long to re-establish supply chains through clandestine channels; the same may happen for tobacco. As with other SEAR countries, India is no stranger to tobacco industry interference, where various tactics are employed to thwart the Government’s efforts at implementing stringent tobacco control policies.^{20, 29} Most of these tactics in developing countries involve financial incentives and arm-twisting. Thus, a ban may prove to be an economic sinkhole for India, a double whammy, where revenue generated from the tobacco industry, which could be used for demand reduction initiatives, may be reduced. The national resources spent on tracking illegal tobacco supply systems will increase, further stretching the law enforcement workforce and expenses ³⁰

Most of these pros and cons point out a pattern of almost definitive immediate inconvenience that may lead to possible gains in the distant future. How ready India is for such a risk remains to be seen.

Conclusion

It is still too early to say whether implementing a generational ban is a good idea or bad. Although the idea of a tobacco-free future is enticing, many challenges and considerations need research and deliberation both before and after the execution of the tobacco endgame interventions. The world, including India, though full of praise for New Zealand, watches with cautious optimism. Inspiration or lesson? Time will tell.