Low and middle-income countries are heavily burdened with tobacco use, especially among low-income populations and marginalised groups. Migrants, women and sexual minorities experience the consequences of tobacco use disproportionately. Tobacco harm reduction ought to be explored in more meaningful ways in these populations for the potential it holds in alleviating their conditions.
The national tobacco control policies designed in developing countries are predominantly geared towards prevention, control and cessation efforts. Tobacco harm reduction is conspicuously missing in the articulation of these policies, because of which there is a lack of awareness even among healthcare providers. While some are aware of narcotics harm reduction programmes and others know about HIV harm prevention through condom promotion activities, that these same principles can be applied to reducing damage from tobacco use is not understood by most. This reveals a profound injustice done to tobacco users and a lost opportunity in a country where approximately 300 million people use tobacco products.
The wide availability of many variants of tobacco, especially the smokeless and chewable forms, and the cultural, religious and social sanction these products have in the Indian society, has led to many rural women becoming early users. There is a need for more gender-centric research to better understand the drivers of this phenomenon and to educate these sub-populations on the hazards of tobacco use, along with exploring suitable harm reduction avenues for them.
There is an opportunity lost in proving tobacco harm reduction training to grassroots healthcare providers, Anganwadi workers and social health activists. To address the tobacco crisis in a country of 1.36 billion people, one needs a trained healthcare force of a variety of health professionals, along with providing them with regular scientific updates and support through systematic channels.
We need to be cautious about the philanthropic interference from western organisations who come with a top-down approach as they feel we do not have the capacities or competencies in delivering optimal health services. A recent example is that of The Union proposing a ban on lower-risk tobacco alternatives in developing countries, which is out of sync with the goals of India’s tobacco control policies.
The availability of lower-risk products suitable for low-income countries is also currently limited, and being novel, governments are taking a cautious and sometimes very restrictive regulatory approach towards them. This is impeding research into evaluating the risk-to-benefit ratios for these alternatives in regional and local contexts, even though studies emerging from the West show them in a favourable light.
Clinical trial-based research into tobacco harm reduction is grossly lacking in the Global South, a divide that urgently needs to be bridged. Being a researcher, it is difficult to see how this gap can be addressed as currently there are no large-scale, multi-centre studies being conducted in developing countries that can evidentially highlight the benefits to policymakers.
A majority of tobacco users in India are also falling through the digital divide, as they are not aware of the means to reduce harm from tobacco use. Nicotine replacement therapies like gums, though widely available, are not known to most users as a way to quit tobacco. Such health inequities in developing countries need to be considered to ensure vulnerable and marginalised groups are covered in national tobacco control policies.