Use of psychoactive substances is regulated by the society or by the government because of a wide variety of reasons linked to health and morality. In general, Indian society tends to discourage people having fun using psychoactive substances. Although people have been using psychoactive substances to change their mental state since time immemorial, they are expected to do so only using the substances approved by the state or the society. This is reflected in the policies and attitudes towards various psychoactive substances. 

India banned all types of electronic nicotine delivery systems in 2019 following the recommendation of an ICMR committee. Several eminent physicians and scientists representing different disciplines were members of the committee, but behavioural scientists and addiction specialists were conspicuously absent from this panel. This means those who understand tobacco or ENDS addiction were not part of the deliberations of the committee that recommended the ban. 

 Absence of psychiatrists and behavioural scientists is a constant in most research on tobacco use disorders. This happens because the authorities tend to not recognise tobacco as a part of a large family of psychoactive substances. This is not the case for other psychoactive substances like alcohol or drugs which are clearly recognised as addictive substances. Whenever there is some discussion on tobacco policies, views of addiction experts and behavioural scientists are not accorded due importance. 

The strategies for managing psychoactive substances can be broadly divided into: Supply control (the ones that control supply of substances), demand reduction (ones that reduce the need to use the substances) and harm reduction (those which minimize the harm without necessarily reducing the use of substances per se. Harm reduction is something more pragmatic - 80 per cent of something is better than 100 per cent of nothing. 

The supply control strategies are the most popular ones despite their lack of effectiveness. Most law-abiding people believe that a ‘ban’ means non-availability. Unfortunately, this is not true. Bans effectively mean that the government is not regulating this substance. The aftermath of bans is quite predictable – criminals and the underworld control the supply of the substance. 

If I purchase a bottle of whiskey in Delhi, I can be reasonably sure that I am buying whiskey. But this is not the case in Bihar and Gujarat which have banned sale of alcohol. If someone buys Ganja in Delhi, they can’t be sure the substance is Ganja or not. E-cigarette liquids contain a high amount of nicotine and various other chemicals. If the government was regulating it, it can keep a tab on the quality of the products consumed by people. Despite the ban, is e-cigarette not available in Delhi? Can anyone be made accountable for what that liquid contains?  Do people use e-cigarettes in India? Yes, there are millions who do. But if the ban is strictly implemented, they will go back to cigarettes and other tobacco products. 

Any discussion on whether e-cigarettes need to be regulated as a harm reduction product or not should also consider what the authorities are doing in the case of combustible tobacco products. While doctors are made to sit and discuss studies on harm reduction products, no one is paying heed to what is happening to the people who use combustible cigarettes for several years. 

The prices of combustible tobacco have been constant in the last two years if we bring inflation to the arithmetic. Prices of almost all essential commodities have increased, but those of combustible tobacco remained unchanged.  

There are various ways in which risk or harm of any substance use can be reduced. The product which people are using can be changed or simply change the context of consuming that drug, thereby reducing the stigma and discrimination associated with it.  So, a wide variety of approaches of the philosophical kind can be applied to the use of psychoactive substances including tobacco. And one of these could be encouraging those to use products with reduced risk. 

 here will always be people using drugs and they need to be offered alternatives. In day-to-day life we know the examples of harm reduction. Condoms, helmets and seat belts are well-known examples of harm reduction. Not drinking, not driving after drinking are also harm reduction the society has accepted, promoted and encouraged. Such initiatives are missing in the case of tobacco.  

The rhetoric for a drug-free or tobacco-free world will not take us anywhere. People will find some way or the other to get nicotine. Whether we like it or not, it is a human requirement. There are some people who simply cannot quit. We need to have empathy towards such people. There are several people who need tea or coffee to remain alert, to remain active. We should stop judging them. 

We need to empathize with people who believe they will not be able to function without nicotine. They require nicotine delivery in one form or the other. Such empathy appears to be missing among policy makers and even among the medical professionals. It is true that the products which are available at this moment for delivering nicotine may not be totally satisfactory. The products which are being marketed may have some issues, but with a ban, we are closing all possible research and development. 

If harm reduction products are recognized as possible alternatives, there is still an option to conduct research to bring about refinement. Nicotine can be further regulated so that nitrosamine and other harmful substances in such products can be reduced to make them even less harmful and relatively safer. 

While there is empathy towards people affected by cancers or heart diseases, those addicted to tobacco do not receive any support. They are also suffering from addiction to tobacco. They are distressed people who require help, empathy, and compassion. 

The government of India’s policies officially endorse harm reduction as an approach to deal with narcotic drugs and psychotropic substances. In other countries, there are other kinds of harm reduction approaches being promoted and encouraged. 

For instance, some countries allow ‘drug consumption rooms’ where people can use their own drugs in the facilities that provide nursing assistance so that if something goes wrong at least their lives can be saved. We may wonder if this is like encouraging people to take more drugs. The point here is saving lives, not making a moralistic judgment about whether the person is doing something right or wrong. 

Our constitution does say about prohibiting some products that are injurious to health. It is not taking a moral stance about using psychoactive substance, but just emphasises the health outcomes which should determine how the government deals with such products. So, the policies such as bans have unintentionally increased the harm from psychoactive substances. 

The ban on availability of opium products appears to have resulted in a heroin epidemic in the country. We are banning e-cigarettes while more harmful combustible cigarettes are available in plenty. This mistake results in unintentionally causing harm maximisation. 

We continue to have high resistance towards tobacco harm reduction which is unfortunate. Amid various moral, scientific and commercial disagreements, we need to sit and find a way around them. Doctors need to work on multiple fronts generating evidence and avoiding all conflict-of-interest type allegations.