Indian oncologists welcomed the US Food and Drug Administration’s (FDA) proposal to limit nicotine levels in cigarettes in that country but said India’s battle against tobacco is far more complex and challenging.
Ganesh Nagarajan, Director - HPB Surgery & Gastrointestinal Oncology, Nanavati Max Super Speciality Hospital, Mumbai, said capping the level of nicotine will directly reduce the incidence of cancer given that nicotine is a highly addictive substance and that reducing its levels could reduce dependence on the carcinogenic substance, but added that would be of limited use in India.
“It’s a welcome step, a lot of cancer specialists have been lobbying a lot to reduce the accessibility of cigarettes, but in semi-urban and rural India, apart from bidis (tobacco wrapped in tendu leaves, which are much cheaper than cigarettes and more easily available in rural areas, chewable tobacco is the reasons behind oral and laryngeal cancer,” he said.
Rahul Bhargava, principal director, haematology-oncology, Fortis Memorial Research Institute, Gurgaon, outside Delhi, too said that a lot of recent cancer cases are from rural India and added that cigarettes form just one component, and that the bulk of tobacco addiction in rural India is due to chewable tobacco.
According to a professional with a US-based multinational company working in the healthcare and pharmaceuticals segment, the largest number of cancer cases in India relate to the neck and head, almost always caused by tobacco consumption, followed by breast cancer. This clearly indicates that chewing tobacco was of greater concern than combustible tobacco when it came to cancer, the person said.
Tough task for India to limit nicotine in tobacco products
When asked if India should also consider limiting nicotine levels in tobacco products, Dr Nagarajan reiterated his point. “In India apart from smoking, people chew it, they use it as toothpaste. It will need huge political will to get something of this sort implemented in India,” he said.
Dr Bharagava said the poor consume chewable tobacco to kill the appetite so that they can work without food. “Social evils need to be dealt with first. Addiction doesn't start at the age of 18 or 20, rather they start taking tobacco at a very small age. This is where the government's holistic approach for tobacco control is needed,” he added.
Akshat Malik, senior consultant, head and neck oncology, Max Hospital in Delhi’s Saket, said that limiting nicotine content in cigarettes will probably bring down the addiction in some but the magnitude of the tobacco problem in India won’t change.
“It’s a step in the right direction but one needs to understand that in the Indian scenario, smoking is just one aspect, one-third of our population consumes tobacco in one form or the other. A majority of Indians are tobacco chewers and not smokers,” Dr Malik added.
FDA’s proposal on limiting nicotine in cigarettes
The FDA is planning to develop a proposed product standard that would establish a maximum nicotine level to reduce the addictiveness of cigarettes and certain other combusted tobacco products.
“Nicotine is powerfully addictive. Lowering nicotine levels to minimally addictive or non-addictive levels would decrease the likelihood that future generations of young people become addicted to cigarettes and help more currently addicted smokers to quit,” FDA commissioner Robert M. Califf said.
According to the FDA, the goal of this potential rule would be to reduce youth use, addiction and death.
“Each year, 480,000 people die prematurely from a smoking-attributed disease, making tobacco use the leading cause of preventable disease and death in the United States. Additionally, tobacco use costs nearly $300 billion a year in direct health care and lost productivity,” FDA said in a statement.
What is nicotine?
Nicotine, one of the additives used in cigarettes and other tobacco products, is an addictive factor and it makes it very hard to quit smoking. It is present in other tobacco products as well, including supari (betel nut, an ingredient in paan), guthka (packaged chewing tobacco made of, among other things, betel nut and tobacco, with a sweet or savoury flavouring) and bidis. Nicotine, apart from being a component which can cause cancer, it also affects the heart.Physicians prescribe nicotine replacement therapies in those who wish to quit smoking.