Electronic Nicotine Delivery Systems Policy Divergence and Surveillance Gaps: A Cancer Prevention Blind Spot in the WHO South-East Asia Region

The unregulated proliferation of electronic nicotine delivery systems (ENDS) across low- and middle-income countries (LMICs) risks undermining decades of progress in global cancer prevention. Nepal's recent regulatory uncertainty, rooted in a mismatch between primary legislation and subordinate regulation, provides an instructive case for comparative policy analysis across the WHO South-East Asia Region, which already carries a disproportionate oral cancer burden attributable to smokeless tobacco use. Using Nepal, India, and Bangladesh as contrasting policy trajectories, we examine how statutory prohibition, legislative reversal, and contested enforcement intersect with this pre-existing burden. Although ENDS may confer harm reduction benefits among certain adults who smoke, realizing this potential depends on effective product regulation, prevention of youth access, and population-level surveillance; these conditions remain weak or nonexistent in many LMICs. We argue that failure to incorporate ENDS explicitly into primary tobacco control legislation constitutes an actionable governance gap. Explicit legislative coverage of ENDS and harmonization of regional surveillance systems represent minimum safeguards before exposure patterns become entrenched and long-term cancer risks can be reliably assessed.