Christmas 2013: Towards a PeacE-Pipe?

When the battle is raging on electronic cigarettes in Europe, a compromise was issued last Wednesday 18th of December from the trilogue between the European Commission, the European Council and the European Parliament. Never the dispute within the scientific community has been more furious on the topic. The position from the trilogue is startling however. At first glance, the Tobacco Products Directive (TPD) was dedicated to… tobacco products. But surprisingly, Article 18 which deals about electronic cigarettes, a real border line tobacco product if any, is the longest article in the TPD! It seems for European instances that electronic cigarettes are considered as the most dangerous issue when regulating tobacco products. May I remind that (to my knowledge) there is not even one case of death due to electronic cigarette use ever reported in the medical or scientific litterature? When the World Health Organization estimates that 100 million deaths occurred during the XXth century, and one billion is expected to occur during the current one, if nothing more is done to prevent them. But a lot has been already done to limit the usage of cigarettes: increase in taxation, ban in public and occupational areas, ban on sales in minors, warning labelling in packaging (even plain packaging in some countries): despite all these efforts, all countries are now facing a plateau in the decrease in prevalence of smoking. We must aknowledge that a dramatic decrease in smoking has been recorded initially. When thinking about the years 1950s, i.e. before Sir Bradford Hill published the causal association found between lung cancer and smoking, more than 90% of British males did smoke. Today, in most countries the prevalence of smoking seems to lay down, for several years, between 20 and 30%. Everywhere? With a striking exception: in Sweden, which is the only country having succeeded to achieve the WHO objective to be below 20% for more than a decade. Sweden had demanded to be able to manufacture and sell snus (which is an oral form of tobacco consumption) in its treaty of adhesion to the EU. Oral tobacco does not kill (when proved of good quality as snus are in Sweden), or at least reduces dramatically its harm, a fact which is visible when comparing national statistics: Sweden has the lowest mortality rates for lung and oral cancers in OECD. If facts are stubborn, that’s nothing in comparison with EU instances and public health experts! Snus do remain banned in European Union (except in Sweden), exactly as illicit drugs are. EU authorities prefer to approve free marketting of cigarettes, which are known to kill one out of two regular users, when banning on snus which are known to reduce smoking habits. EU is backed by many experts in tobacco who maintain that these smokeless products are a gateway for smoking. They point out the (indeed cynical) role of tobacco industries which are planing to lure consumers with these nicotine substitutes just for creating an addiction leading to regular cigarettes thereafter. During this time the real killer drugs, i.e. cigarettes, are still on the market. Facts are totally against any form of gateway regarding the use of snus in Sweden, since as I wrote earlier, Sweden is the country which has the lowest prevalence of smoking in Europe, but who really care about facts?

There are many financial issues behing this battle, and it is difficult to know to what extent they play a role, and which one, among states, politicians and experts. In France only, cigarettes reward the state by 17 billion euros, just in taxes. It represents a real addiction to taxes, which may be not easy to withdraw. Although it has been stated that smoking cost 47 billion euro to the French society (social security, insurance system, employers), these costs seem hidden to the state, and more than that time span is not the same, since benefits from stopping smoking may not be visible immediately for delayed diseases such as lung cancers or chronic bronchitis. Anyway, tobacco industry has never been as wealthy as today. None of the intervention measures taken to limit cigarette use has succeeded to decrease their benefits. This industry always find new markets and other markets. It becomes hard to know exactly what covers tobacco industry today. For example, Philip Morris has bought Kraft, a major food company which markets the brand Suchard, manufacturer of Toblerone, did you know that? Analysts consider however that electronic cigarettes may constitute a real threat to the tobacco industry. Electronic cigarettes are mostly manufactured and sold by small companies today. The market is highly fragmented today. Initiated in China, it widespreads quickly particularly in the USA and Europe. Tobacco industry is inevitably trying to buy electronic cigarettes retailers and manufacturers. This market represents still a little fraction of the sale of tobacco products, but will reach 500 million euro in Europe and 1.7 billion dollars in the USA this year (2013) according to a recent paper published in the New England Journal of Medicine last Dec. 18 (available for free on line). Their authors, Amy Fairchild et al. from the Columbia Mailman School of Public Health at NYC, present arguments from both sides, those who prone total abstinence, and those who favor harm reduction even without full certainty about risks of ecigs. The authors conclude their perspective paper choosing clearly their camp: “We may not be able to rid the public sphere of “vaping,” but given the magnitude of tobacco-related deaths — some 6 million globally every year and 400,000 in the United States, disproportionately among people at the lower end of the socioeconomic spectrum — an unwillingness to consider e-cigarette use until all risks or uncertainties are eliminated strays dangerously close to dogmatism

Activists are claiming their rage shouting at a level that has not been seen since the AIDS era, when they were at origin of most plans against HIV infection, promoting condoms, demanding access to antiviral drugs to low income populations. Today activists for electronic cigarettes need a strong commitment and support from doctors, experts and politicians. We need to give up our former dogmas here, and to accept the idea that abstinence regarding tobacco is not a better strategy for fighting smoking than it was against sexually transmitted infections. I am calling for a real politik in terms of tobacco control, including a harm reduction strategy, aknowledging addiction to nicotine in society, which is not per se the cause of smoking devastation. Smoking related diseases are caused – that is for sure – by tars and carbon monoxyde which are produced by combustion, i.e. burning tobacco, not due to nicotine. This real politik must take place now in the European public health policy: Article 18 needs to be removed from the TPD. We must distinguish totally smokeless tobacco products, including snus and electronic cigarettes, from all other forms of smoking tobacco.

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