Smoking cessation and e-cigarettes in China and India

The Chinese and Indian governments have taken steps to restrict access to electronic cigarettes.12 The motivation has been to protect young people from e-cigarette use and possible lifelong addiction and, less altruistically, lobbying by domestic cigarette industries. Protecting young people is a laudable goal but it must be scrutinised using epidemiological evidence relevant to each country.

Prolonged tobacco smoking causes about a million deaths annually in both China and India.345 China and India have about 300 million and 100 million smokers, respectively, about a third of the global total of 1.3 billion smokers. Although smoking prevalence has fallen in India over the past decade, in China it is mostly unchanged. Few women smoke in either country.6 Importantly, among people aged 30-59—an age when adults often consider quitting—there are about 250 million Chinese and Indian men who currently smoke but only about 30 million former smokers. In China, only 10% of male smokers have tried quitting in the past year.6 By contrast, in high income countries, around age 50 there are as many former smokers as current smokers.3

Quitting before the age of 40 (and preferably earlier) avoids 90% of the risk of continued smoking.3 Reductions in tobacco deaths in these two countries (and globally) over the next few decades will require large increases in cessation rates. Preventing children from starting to smoke would reduce mortality only after 2050. E-cigarettes produced higher cessation rates than more standard nicotine replacement therapy in a randomised trial7 and seem to have raised adult smoking cessation in England.8

Notably, less than a third of male cigarette smokers in China and India start before age 18, whereas in the US and UK most regular smokers start before this age.6 Moreover, female smoking at ages 18-24 years is low and probably falling.34 This is relevant as most (but not all) studies in high income countries find that e-cigarette experimentation occurs mostly among cigarette smokers and is low among people who have never smoked.9 E-cigarettes might be contributing to historically rapid declines in cigarette smoking by US high school students.10

China and India have implemented some of the provisions in the Framework Convention on Tobacco Control, most notably by banning smoking in public places and restricting tobacco advertising or promotion. However, both have mostly neglected high excise taxes, the single most effective intervention to raise adult cessation and deter young people from starting.311 Rapid income growth, especially in China, means that cigarettes are now more affordable. The profile of smoking in China and India suggests a debate is needed on the role of e-cigarettes, with much greater attention given to the challenge of raising the low cessation rates among middle aged adults. Paradoxically, the tight restrictions on e-cigarettes in China and India represent an opportunity for a more deliberate and measured approach to e-cigarettes than has been possible in many high income countries.