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Evaluating the efficacy and affordability

of risk-reduced vaping products for bidi

smokers in India.

OCTOBER 16, 2019

Project report by: Samrat Chowdhery

Developed with funding from KAC Global State of

Tobacco Harm Reduction Scholarships

CAN INDIA’S BIDI SMOKERS BE SWITCHED TO LOWER-RISK ALTERNATIVES?

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Contents Aims and Objectives ...................................................................................................2

Methodology ..............................................................................................................3

Outcomes ...................................................................................................................7

Learnings .................................................................................................................. 10

Aims and Objectives

India has nearly 100 million adult smokers. According to the World Health Organization

(WHO), the country is home to 12% of the world's smoking population. More than a

million Indians die every year due to tobacco-related illnesses, accounting for 9.5% of all

deaths in the country. Bidi smoking comprises the highest risk category, leading to

nearly 80% of deaths caused by tobacco use.

A bidi is a thin cigarette or mini-cigar filled with tobacco flake and commonly wrapped

in a Tendu (Diospyros melanoxylon) or Piliostigma racemosum leaf and tied with a

string or adhesive at one end. Bidi use accounts for

most (81%) of the tobacco smoked and 72 million

regular users over the age of 15. Although

bidiscontain less tobacco than conventional

cigarettes, the nicotine content is significantly higher,

and the relatively low burn point forces smokers to

breathe in more of the harmful chemicals produced.

Bidi smoking costs India INR 805.5 billion annually in

ill health and early death.

Prevalent in low-income groups, bidi smokers also have the least access to medical care

and the public healthcare system in the country is unable to address their health needs.

Prevention is therefore key in this group, and tobacco harm reduction can lead to

significant gains. This project was designed to evaluate the effectiveness and

affordability of lower-risk alternatives (eg. E-cigarettes) for bidi smokers in India.

Picture 1: Bidi is a local form of handrolled smoking tobacco.

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Methodology

We enrolled over 130 bidi smokers in the Mumbai region who expressed willingness to

quit by trying out e-cigarettes as a safer alternative. We gave them e-cigarette devices,

change of coils and liquids for three months. The program was rolled out in two phases

– in the first, the backend was set up and a sample group of 10 bidi smokers were

enrolled for testing the devices and liquids, after which a larger group of 120 bidi users

were given devices and liquids to evaluate the effectiveness of Electronic Nicotine

Delivery Systems (ENDS).

Phase 1 The program was developed from the ground up – program partners were taken on

board, a supply chain was created and project guidelines were put in place.

Among the two program priorities, the affordability of low-risk solutions was addressed

first through market research and analysis to determine average tobacco spending in

this group, and identifying vendors.

Specifically, the following were done:

COST ANALYSIS: The first step was to gauge how much an average bidi smoker spends

on the habit. We did a survey of various locations and sought information from other

cities on the retail price of a packet of bidis. Unlike cigarettes which are primarily sold

loose in India, bidis are mostly sold in packets. The price varied from Rs 12 to Rs 26 per

pack. We averaged it to Rs 15 a day, which is Rs 450 a month. The safer-alternative

solution had to work inside this range for it to be cost-effective over a long term.

SUPPLIERS: The next step was to identify equipment retailers who were: a) interested

in servicing the bidi segment, b) had the capacity to procure ENDS at low cost, c) were

willing to freeze the pricing for up to a year as this category is extremely price-sensitive

and we wanted to ensure the bidi smokers can continue to have access to liquids and

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devices at low cost after the three-month program period was over, d) could maintain

product quality, and e) saw an economic opportunity and were keen to stay in this

category for the long term.

A number of vendors were contacted to learn which devices would work best and the

price at which they can be retailed. Along with the cost, the parameters were that the

devices should be sturdy and last reasonably long, the tanks should hold a good

quantity of liquid, there should be no known battery issues, they should be available in

large quantities if needed, and prices can be guaranteed over a period of time so that

the solution can be effective even in a business environment and not just in a research

setting as there is high likelihood that those who switch successfully would attract

others to try it too.

Two low-cost options were zeroed in on – CE6

and CE5 pens. The clear advantage of the

former was replaceable coils which would

have brought the overall cost-to-user down in

a big way. However, availability and pricing of

CE6 pens were an issue. I waited for almost 2

months to get them from China, but later

settled on the CE5 pens to avoid delays. The

supplier who was finalized is helping roll out

the initiative, sensing a business opportunity in

understanding how bidi smokers can be switched, which also works well for the overall

goals of focusing commercial attention on this segment where harm reduction can be

the most impactful.

Picture 2: Vape pens procured.

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LIQUID MANUFACTURERS: The third step was

to bring onboard a local manufacturer of e-

liquids who will be a critical part of the

program by fine-tuning the liquids in

accordance with feedback. It was also

important to partner with someone who

would be able to produce liquids at the right

cost, while maintaining a certain quality

standard and ensuring continuous availability. After discussing the project with a

number of manufacturers, we decided to go with a smaller vendor who also does social

work with tribal populations as these would be one of the communities we will reach

out to in the coming days. Getting the liquid right was the first phase – we worked with

a few options, and finally decided to go with a tendu-flavoured liquid with 18mg

strength. Bidis are rolled in tendu leaves, so the flavor matches those of bidis and

would be easier to transition with.

PROJECT GUIDELINE: To ensure streamlined implementation a project outline was

developed, with specific instructions for first and second contacts. A copy will be found

in the Annex to the report.

Picture 3: Bidi-flavoured liquids procured.

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IMPLEMENTATION: The final step was to roll out the program. We stayed away from

de-addiction centres to avoid medicalisation of the project and focused on finding bidi

smokers at a location where they can be contacted regularly for feedback to gauge the

effectiveness of the

intervention and test

modifications based on it.

A few options were

zeroed in on – security

guards of buildings in an

area who smoke bidis,

labourers at construction

sites, and residents of

tribal villages. In the first

rollout, we interacted with

bidi smokers at a construction site, and after evaluating willingness and need, we gave

the kit and the liquid to four people of differing age-groups and frequency of use.

Thereafter, consultations were held with bidi smokers working on the construction of a

temple (cover pic). They were sensitized on the harms of tobacco use and offered a way

out of the dangerous habit through harm reduction. The participants showed

willingness to enroll – six kits were given out, including to the site in-charge.

The participants provided valuable feedback that helped guide the program, which is

outlined in the Learnings section. The quit rate in this group was zero. This was

attributed to frequent changes in liquid formulation and lack of continued support (eg,

some participants felt the devices had stopped working, though the problem was

improper charging). These issues were adequately addressed in the second phase.

Picture 4: First batch of bidi smokers being enrolled.

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Phase 2

After the product testing and developing a reasonable understanding of what works for

the bidi smoking population, a structure was created to expand the program to more

bidi smokers. Four Outreach Executives were taken on board and provided training in

identifying, counselling and enrolling bidi smokers in the Mumbai suburb of Mira Road

which has high construction activity which employs a large number of labourers, most

of whom are tobacco users, with

high prevalence of bidi use. A

strong focus was laid on the safety

aspects, which include instructions

on safe use and reporting any

significant health changes.

The Outreach Executives also

received strict instructions on

ensuring there is no resultant teen

use – not enrolling anyone who

looks young and whose age cannot

be verified, focus on long-term users, instructions to participants not to share the

devices with a teen, as they would not share a bidi, and keep the devices (and liquids)

in a safe place.

The Outreach Executives enrolled over 120 participants in an ongoing exercise. The

executives went to construction sites, factories and tobacco shops to find interested

participants. Regular follow-ups were conducted to assess continued use and identify

problems. Extra liquids were provided to those who had finished the first one.

Outcomes In total, over 130 bidi smokers participated in the program. Over 90% of them are still

using the devices, with some making a complete switch and quitting bidi use

altogether.

Picture 5: The team (clockwise from left) - Samrat Chowdhery, Dharmendra Rai, Jitu Diwakar, Virendra Lodhi, Rohit Yadav and Bilal Mansourie.

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Phase 1 comprised a test group of 10 bidi users. Though none of them made a long-

term switch to ENDS, the inputs provided by them were of significant help in

developing the program. These inputs are outlined below:

1) Flavoring: Bidi has a unique, strong flavor. The participants were most

comfortable with bidi flavored liquids and were sensitive to changes in flavor.

Some complained about the lack of taste when a lighter-flavored liquid was

distributed among them. It is not certain whether their palette will change to

adopt more flavorings after continued use.

2) Nicotine strength: At first, a freebase 18mg liquid was distributed among the

participants. They found this to be harsh and complained of continuous

coughing. The harshness is likely to have been accentuated by the strong bidi

flavouring. The nicotine strength was thereafter brought down to 12 mg, which

seemed to work fine even though bidi delivers a high amount of nicotine.

3) Devices: Though there were hiccups with the devices at the start, with some

failing to function, this problem was later identified to be improper charging.

Battery life is a crucial factor since many don’t have daylong access to charging

points. This can somewhat be addressed by higher strength nicotine liquids,

though to avoid the throat hit, use of salt nicotine may be necessary. However,

salt nicotine is a lot more expensive, and studies on mixing salt and freebase

variants can help inform if this can be a low-cost solution.

4) Counselling: A strong need was felt for proper guidance on device use and

continued assistance for a period of time until there is some familiarity with use.

5) Availability: Easy availability of liquids and devices will play a vital role in making

the switch possible.

6) Price-sensitivity: This tobacco users group was highly sensitive to pricing, with

slight increases likely to suppress desire to switch.

The second phase involved over 130 bidi smokers in the age range of 20 to 58 years.

Though all belonging to the low-income group, they come from varied professional and

cultural backgrounds and from different regions in India as a number of them are

migrants from villages, towns and cities across the country.

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Picture 6: Bidi smokers from various professional and cultural backgrounds were enrolled in the project.

A progress report outlining the follow-up responses was compiled. The follow-ups were

conducted bi-weekly at the start to ensure smooth transition to ENDS and to identify

and address concerns.

Key Findings

1) Desire to quit: A key finding has been that, despite the common perception that

the desire to quit is low among bidi smokers, a number of participants expressed

a desire to stop bidi smoking and some of them actively used ENDS to completely

switch, and quit. Further, some curtailed their ENDS use to only during mornings

and after food consumption when the urge to smoke is highest. All these show

the willingness to quit smoking. It is, however, to be ascertained what the

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contributing factors are – age, education, profession, duration of tobacco habit,

health factors etc. Identifying them will help design more effective and targeted

cessation programs.

2) Transition: There was overall willingness to try out a safer alternative, though it

is not clear how well the concept of harm reduction is understood. Most

participants who continued using the device for over a week stuck with it. There

were complaints about sore throat and in some cases the devices stopped

working. Addressing these issues can improve effectiveness of ENDS. One way

being explored is to procure slightly better quality devices, though still within

affordable range. This could also solve the spit-back issue faced by some

participants. There was no feedback on nicotine strength, hence it is assumed

12mg strength could be ideal for this group.

3) Consumption: Out of the approximately 120 participants, about 20% finished

10ml of liquid in two weeks. This is an unexplained factor that could mean a few

things – the participants are finding the nicotine strength high and are using the

device and liquid less, they are acclimatising to ENDS use, they are using the

device minimally to quit nicotine dependence altogether (some respondents said

as much during follow-ups), there is dual use, or the participants are mis-

reporting ENDS use. Further analysis of this aspect is needed through more

interaction with the participants.

4) Societal impact: One of the concerns was how ENDS would be viewed in the

wider community in which the bidi smokers live – will an electronic device be

adopted and used without perception barriers, both among the users and those

around them. Perhaps because of growing familiarity with gadgets, primarily

cellphones, no such hindrance was recorded. Family members infact appreciated

the transition and commended our team on helping the smokers switch.

Learnings

The cost analysis shows the first aim of the project, to gauge the cost-effectiveness of

ENDS for bidi smokers, is fairly achievable. At a monthly average spend of Rs 450, a bidi

smoker can transition to lower-risk alternatives with ease. The device being distributed

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costs Rs 200, while liquids cost Rs 60 for 10 ml and coils can be replaced for Rs 20-30.

These prices can be brought down much further with increase in volumes.

There is high need for awareness and interaction programs through which tobacco

users in this income group can be made aware of harm reduction through lower-risk

alternatives – no one we interacted with knew about these devices, some thought it

was a hookah. This should be followed by counselling and handholding to help them

transition. We found adequate willingness to try out an alternative if it works and fits

within their budget and lifestyle.

This second part, understanding how effective these devices are for bidi smokers and

whether they would be socially acceptable for them to use, has shown encouraging

outcomes. The urban poor are well-poised to adopt ENDS as they are not wary of using

electronic devices and have sufficient access to battery charging. Availability and

affordability will play a crucial role in helping them make the switch.

Mobile, on-site counselling is beneficial, which can be further built upon through a

cessation centre so that bidi users can benefit from word-to-mouth recommendations

from those who have transitioned, and have continued access to counselling and

technical support.

For businesses, launching products targeted at this segment can be lucrative as there is

good access to ingredients, including liquid nicotine, and low-end device manufacturing.

There will be need for sustained investment and initiatives to grow the category

through awareness and sensitization campaigns.

The government can provide a strong push by incentivising businesses to launch low-

cost alternatives to bidi smoking.

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Annex: PROJECT GUIDELINE

Switching bidi smokers to lower-risk alternatives

Overview

Project Background and Description

This project will examine whether and how bidi smokers can be transitioned to ENDS, with focus on affordability and effectiveness.

While in theory electronic cigarettes should work for a bidi smoker, this has not been tested, nor is it understood what peculiarities

such a transition would entail. Moreover, a detailed study of the cost-effectiveness of currently available ENDS and liquids for bidi

smokers is needed.

Methodology

We will enroll 20 bidi smokers in small groups across Mumbai who express willingness to try out a safer alternative and give them

devices, change of coils and liquids for three months. Users will be sensitised to the benefits of switching and the participants will be

identified. Monitoring will be done through weekly/fortnightly interactions to record and understand their needs and concerns. The

feedback will be addressed (higher nicotine, PG/VG ratio, flavoring, coil change frequency, viability of device, etc). A cost-sheet will be

prepared for procurement of devices, manufacture of juices and distribution. The target areas for enrolment are construction sites and

tribal villages.

High-Level Requirements

The program requires the participation and involvement of the following stakeholders:

• Vendor: Will procure the devices/replacement coils and ensure uninterrupted supply of essentials.

• E-liquid manufacturer: Will make e-liquids to requirement and incorporate user feedback.

PROJECT OUTLINE

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• On-ground support: Will roll out the project among participants and monitor/relay feedback.

• Medical supervisor: Will monitor health parameters of participants.

• Accountant: Will record expenses and ensure the cost-effectiveness of ENDS for bidi smokers.

Deliverables

A project report will be prepared which will be shared with lawmakers and the scientific community to highlight the possibility of

reducing harm among the bidi smoking population. The project will help guide policymaking and encourage further research into

mitigating harm through lower-risk alternatives.

By ensuring the solution is affordable for the target population, a long-term supply network will be built which those who have

switched can rely on for further supplies and for expansion of the service to other bidi smokers.

A detailed listing of the feedbacks and respective solutions will provide a framework for other sectoral businesses to target services to

bidi smokers in the country.

FIRST CONTACT Target-specific guidelines to enroll participants.

Objective Actions

Gauge willingness

Before the program is rolled out, it is important to ensure the candidates have some desire to mitigate harm to themselves and give a lower-risk alternative a try. This can be done by asking specific questions:

1) Have you faced any problems like coughing, loss of stamina and appetite, illness or any other discomfort because of smoking bidis?

2) Have you ever tried to quit smoking bidis because of these problems?

3) Has any family member complained of discomfort because of your bidi habit?

Present the alternative

1) Will you be willing to try an alternative which does not create the above problems, does not harm you as much, while satisfying your urge to smoke?

2) To try it, you will have to pledge that you will use it continuously for a week under any circumstances. Will you be willing to do so?

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Explain how it is safer

Show them the device, and explain how it works with these statements:

1) Most of the harm from bidi comes from burning of the tobacco leaf. The burning produces tar, which is what causes the majority of the harm

2) In this new device, there is no burning and hence no tar. It however feels just like smoking as it contains nicotine, but without the harmful effects

3) By switching from bidi to vaping, you will not only reduce harm and the ill-effects of smoking to yourself, but also to those around you. It does not produce a bad smell

Show them how it works

Give them a demo on how to use it:

1) How to fill the juice and how to charge. Let them know the charge lasts for 3-4 hours depending on usage, so they need to plug it into some power source

2) Tell them when to refill (when they see the juice level go below a mark or when they get dry hits)

Explain the don’ts

Things not to do with the device:

1) Do not let kids near it or use it (you won’t let them use your bidis, so not this either)

2) Explain battery safety (don’t leave unattended, unplug if battery overheats)

Motivate 1) If you try this for a week you will see immediate change. You will be able to breathe better, morning cough will subside, your taste will be back and you will smell better

2) There might be some physical discomfort at the start as the way your body gets nicotine is changing. You might experience some cough as this is vapour not smoke, but the throat irritation will go away in 2-3 days. Stick through this phase

3) Try to use this device exclusively, and if the urge is too strong, smoke a bidi and return to using the device. Keep using it even if you smoke some bidis a day

4) You may notice some dehydration. Drink enough water

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Important

1) Collect names, age, profession, telephone numbers, residential address of participants 2) Ensure no one has serious ailments 3) Determine time/date/venue of next session, ideally a week from the day 4) Give them your number for queries. Do a follow-up call in 2-3 days to check usage 5) Record the entire interaction on video or audio. Take some pictures

FIRST follow-up Target-specific guidelines to get feedback.

Objective Actions

Ascertain use

1) Have you been using the device regularly? Was it exclusive use?

2) If not, how many fewer bidis have you smoked per day?

Determine challenges

1) Do you think this can be a long-term solution for you? If not, why? If yes, why?

2) What did you like and not like about the device? 3) What are the key differences between using this device and

bidis? 4) Did you notice any change in health?

Specific feedback

1) How many times did you have to charge the device? Is it inconvenient to do so?

2) How often did you need to refill the juice? 3) Does it satisfy you and do you feel like smoking? 4) Is the drag okay? Would you prefer to puff harder or softer? 5) Is the flavor okay? What kind would you prefer – more

bitter/bidi flavor? 6) Any other feedback which will make it more effective and

user-friendly

How to replace coils

Give them a demo of how to replace the atomizer/coil, and how to identify when to replace it

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Inform about affordability

Let them know that we are doing this project for a few months during which time the devices and juices will be distributed free of cost. However, once they switch they can continue to use as there is a long-term network available:

1) The kit costs Rs 200 at present, but the prices will come down over time

2) The replacement coils cost about Rs 30 3) The juice costs Rs 30-40 for 10 ml 4) They will be able to choose flavors in the future. Tell them

what flavors are possible 5) They will be able to get these easily, through you at first,

later through local panwala

Referral Though this project is for them only, if they like the device they can refer it to others willing to try

Motivate 1) A million people die of tobacco use in India every year, a majority of whom are bidi smokers. If you continue to use this device, you will greatly reduce the harm to yourself and those around you

2) It costs less and definitely not more than bidis, while the risk is far lower

3) Continue using it even if you are still smoking and gradually try to cut down on bidis with the goal of switching completely

Important

1) Collect specific feedback which can be used to modify juices 2) Ask participants if they will be willing to take before/after tests 3) Let them know their suggestions will be incorporated and new juices made accordingly, so don’t give up 4) Fix date/time/venue for next follow-up, ideally in a week or 10 days 5) Record the entire interaction on video or audio. Take some pictures