INTRODUCTION

With about 267 million tobacco smokers, India is the world’s second-largest consumer of tobacco products. There are 100 million tobacco smokers among them, and over 199 million people who use smokeless tobacco¹. Recent global trends have shown the emergence of electronic nicotine delivery systems (ENDS; also known as electronic cigarettes or e-cigarettes). These non-combustible tobacco products, also known by many names such as vapes, e-hookahs, vape pens, e-cigars, and e-pipes, are marketed as tobacco-free nicotine delivery battery-operated devices which produce an aerosol by heating a solution containing nicotine, among other things, instead of burning tobacco leaves in traditional cigarettes².

Numerous studies have highlighted an increased awareness about e-cigarettes in developed countries^3,4. Little is known about e-cigarettes in middle-income countries, many of which, like Mexico, banned sales and marketing of e-cigarettes⁵. Understanding country-specific data on e-cigarettes is vital in understanding their growth patterns so that appropriate public health interventions and policies can be planned. To address the need for nationally representative surveillance data on e-cigarette use, the Global Tobacco Surveillance System of a few countries, including Indonesia, Malaysia, Qatar, and Greece, incorporated questions on e-cigarettes into the Global Adult Tobacco Survey (GATS) in 2011⁶. However, India incorporated these questions in the second round of GATS (2015–2016)¹. The GATS (2015–2016) was carried out before the promulgation of the Act. Despite the low proportion of e-cigarette users (1.22%) reported in the survey¹, the Government of India went ahead with placing a ban on the same. The current analysis presents nationally representative findings on the level of awareness of e-cigarettes in India and its correlates.

METHODS

RESULTS

DISCUSSION

The current study highlighted a low level of awareness about e-cigarettes among the adult population in India. This is probably the first large study from India that documents the awareness of e-cigarettes and the characteristics of vapers before the ENDS ban in the country. Despite a lower awareness and use, the promulgation of the ENDS ban in the year 2019 demonstrates the strong commitment of the Government of India to counter tobacco industryled nefarious strategies to promote e-cigarette use. The Indian e-cigarette market reached a value of $7.8 million in 2018, and it is further predicted to witness a compound annual growth rate of 26.4% during the forecast period (2019–2024)⁷. Owing to the limited literature available for low- and middle-income countries, the current study was planned to develop an evidence base from India on the level of awareness of e-cigarettes.

Awareness of e-cigarettes was found to be more among young males in the current study. Peer pressure, social media exposure, and trend were major factors for its higher awareness in this age group^3,4. The working population and students were found to be more aware of e-cigarettes than the unemployed, which may be due to their high likelihood of trying regular tobacco products and then gradually increasing intention to indulge in other smoking products, as has also been demonstrated in other studies⁸. E-cigarette marketing focusing on the productive age group could be an essential determinant in increased awareness in this group⁹. The widespread availability of articles explaining how to procure and use ENDS on the internet has also led to increased awareness among the youth¹⁰. Tobacco smokers were less aware of e-cigarettes compared to non-smokers. This may be due to the perception that e-cigarettes are less harmful than conventional tobacco smoking and perceived these to be a cessation tool¹¹. Further, it also could be because at the time of survey, the respondents had less exposure to scientific evidence about the harm of e-cigarettes and relied on anecdotal evidence. Also, perhaps the smoker prefers to buy a single stick instead of the entire package and hence misses out on the pack warning.

The current study provides preliminary evidence on the characteristics of those aware of e-cigarettes and their factors before the ban, which could be helpful for policymakers in making apt decisions and designing appropriate policies for strict enforcement and implementation of the ENDS ban.

CONCLUSIONS

Overall there was low awareness of e-cigarettes among the Indian population. Awareness was higher among males, younger age group, students, urban population, respondents who had a higher level of education, and the highest wealth quintile. Therefore, there is a need for explicitly targeted information and education campaigns (worksites and universities) about ENDS. Besides, sensitization and capacity building of stakeholder departments for effective implementation of the legislation [The Prohibition of Electronic Cigarettes (Production, Manufacture, Import, Export, Transport, Sale, Distribution, Storage and Advertisement) Act, 2019]¹² and compliance monitoring should be carried out. A robust surveillance mechanism should monitor e-retail stores for sales and digital platforms regarding the advertisement of ENDS and like products.