No Tobacco Day: the possible way to reduce risk
Smoking cessation policy alone cannot work, but there are alternatives. The issue of risk reduction linked to new smokeless devices continues to be unexplored.
For the second year No Tobacco Day, established by the World Health Organisation in 1988, crosses the pandemic and, consequently, in-person events are excluded.
For Italy, the Istituto Superiore di Sanità (ISS) has organised an online event on Monday 31 May, which will present updated data on smokers in our country. “Commit to quitting”: this is the motto accompanying the initiative. A necessary but also difficult commitment, considering the annual death toll from tobacco-related diseases.
These figures are unfortunately stable, despite the moderate reduction in the number of smokers over the last 15 years. It should be considered that Covid deaths attributable – the most dramatic pandemic in a century – have been around 125,000 in 15 months in Italy. Fortunately, the Coronavirus is being effectively controlled and, therefore, defeated. Tobacco-related deaths, on the other hand, are set to occur in constant numbers over the next few years. There is, in fact, no equivalent to a vaccine for smoking.
Eurispes has always been involved in public health issues and, has often agreed with the positions of the Ministry and the Istituto Superiore di Sanità on these issues.
After the 2003 laws restricting the freedom to smoke in public spaces, however, our Institute believes that not enough has been done to further contain the number of smokers and the social and health impacts of smoking.
The Ministry of Health uses the data provided by the Tobacco Atlas, which estimated 93,300 victims of tobacco-related diseases in 2016, while the British Medical Journal estimated a cost to Italian public health of over EUR 9 billion in 2018. However, given these figures, the ‘recipe’ put forward so far is almost exclusively that of a call to quit.
From the surveys carried out by Eurispes over the years, it is clear that an overwhelming majority of the approximately 11.5 million smokers are unable or unwilling to even try to ‘quit’. More than one smoker in five (21.9%) has no intention of quitting smoking (“absolutely not” is the explicit answer). Almost a third of the sample (30.5%) states that they should, but do not want to, and 26.3% should, but do not believe they can, while 12.3% of the respondents would like to quit, but not in the short term. Only 9% aim to do so within six months.
For these “reluctant quitters”, the instruments offered by public health are not very effective. It should be noted that public and contracted smoke-free centres are responsible for an annual average of less than 10,000 smokers seeking help to quit. On the other hand, the Eurispes surveys show that even general practitioners are not very active in advising their patients to quit or limit their smoking: 56.6% of smokers have never received any advice from their doctor on the subject (31.5% state, however, that they have been encouraged to quit smoking and 11.9% have been advised to switch to a less harmful product).
Is there another concrete policy against smoking harm reduction? According to Eurispes, the risk reduction linked to new non-combustion devices should be considered, a topic that the Institute has been working on for years, also thanks to the collaboration with associations and companies in the sector[1]. Liquid vaporizers – so-called electronic cigarettes – and heated tobacco have for some years now offered an alternative to combustion tobacco, to the point where one no longer we have to speak of “smoking” as such while referring to those products. Many independent studies have shown that these products have the potential to reduce risk, and these should continue to assess the residual problematic impacts of ‘vaping’ and inhaling tobacco vapour.
But the logic of risk reduction is formally rejected by Italian health authorities. The ‘precautionary principle’, which leads to focus on the potential negative, albeit reduced, impacts of new products, thus totally ignores the principle of harm reduction. In this, the Italian authorities are following the indications of the World Health Organisation, which is also very reluctant to “clear” the use of these new instruments, which, moreover, are gaining ground by taking away space from traditional smoking. But the Ministry goes even further, to rule out harm reduction as a public health objective. As recently as last February, the Director General for Prevention, Professor Giovanni Rezza, stated: “The risk or harm reduction approach (…) in the current state of evidence, cannot be adopted as a public health strategy, which aims instead at smoking cessation by using tobacco products or products containing nicotine”.
We are confident that on this year’s No Tobacco Day, these will be the positions expressed. Not divergent positions can be found in some other important nations. But this is not the case everywhere. In Great Britain, for example, the situation is even reversed. The Ministry of Health has been officially promoting vaping as a means of giving up smoking for years. Last April, British Health Secretary Jo Churchill told the House of Commons: “The Department encourages all smokers to quit or switch to less harmful products, such as e-cigarettes, if they are unable to quit. In England, around 2.5 million people use e-cigarettes, most of whom no longer smoke. In addition, about 50,000 people a year quit smoking by switching to e-cigarettes, people who would not have quit by any other means”.
What’s more, a cross-party group on vaping is active in the British Parliament, which has produced a report that has gone so far as to threaten to cancel the British financial contribution to the World Health Organisation if it does not change its “overly cautious” stance on “electronic smoking”.
In France, the Pasteur Institute has reported that vaping is around 1 on the toxicity scale, with 100 being the value of a traditional cigarette. Back in Italy, Professor Fabio Beatrice, Director of the San Giovanni Bosco Smoke-Free Centre in Turin and one of the Italian clinicians who tested the effectiveness of the new tobacco control tools the most, makes the following assessment: “We need more openness. We need to get past the stadium curves and the ‘for’ and ‘against’ logic. In the anti-smoking centre I run, when cessation proves difficult for the patient, the support of the new tools is effective. The Ministry and the National Institute of Health cannot disregard the evidence, and risk reduction policies should not be covered up. Public health cannot just say to people to ‘stop’. It must also take care of those who cannot or do not want to. As doctors, we have an obligation to treat, not to cure.
In the meantime, new tools are becoming increasingly popular. In Japan, heated tobacco has taken over 20% of the traditional smoking market. In Italy, an Eurispes survey for 2019 shows that users, including occasional and dual users, of e-cigarettes amount to 20.8% of smokers, those of heated tobacco products to 7.2%.
As far as European countries are concerned, these new instruments have generated an interesting production and distribution chain involving hundreds of small and medium-sized companies and thousands of specialised shops. Umberto Roccatti is the President of Anafe, the association of manufacturers and distributors in the vaping area which is a member of Confindustria, and Vice President of Ieva, the equivalent European association. In view of COP 9, which will lead to a discussion on tobacco and the new instruments in the autumn, he summarises the expectations of the industry players: “We expect a progressive recognition of the reduced risk associated with the new instruments, and the enhancement of their complementarity in the fight against smoking. For e-cigs, a differentiation in regulation from tobacco. More generally, a regulatory evolution allowing a progressive development of our sector, which is also very important from an employment point of view. For Italy, in particular, the possibility of a dialogue with health authorities that would allow us to inform citizens correctly. This is one of the reasons why Eurispes is drafting a proposal for a strict code of self-regulation to ensure maximum fairness in their sale, in physical shops and online. Consumer information and maximum protection for minors: these are our objectives.
In conclusion, Eurispes points out that the “no to tobacco” must not remain an empty slogan and an abstract expression of purpose. Much still needs to be done, and the public health toolbox should include risk reduction and smoke-free tools.
1] See, among others, the survey conducted with ENPAM, also with the contribution of Philip Morris Italia, published in December 2020 on the Eurispes website at the following link: https://eurispes.eu/news/il-fumo-in-italia-tra-abitudini-consolidate-e-nuove-tendenze/
