Monday 24 May 2021

Conflicting tobacco control advice in post-Brexit Europe

Last week European public health experts made public their advice to governments on how to strengthen tobacco control in their jurisdictions. These reports were all prepared by knowledgeable and experienced experts and were based on the same body of evidence. Nonetheless, they came to very different conclusions and pointed governments in very different directions. Increasingly, the English Channel has become the dividing line between scientists who are e-cigarette enthusiasts and those who are not.

This post reports on the release of these reports and the significance this could have for Canadian policy-makers.

Report from the European Commission (May 20, 2021)

The 27 Member States of the European Union have agreed on a common approach to tobacco regulation, with minimum standards applying across the region and options for countries to go further if they desire. The current Tobacco Products Directive was adopted in 2014 and came into effect in 2016. In anticipation of revisions to the law, EU officials were tasked with providing legislators with an analysis of its strengths and weaknesses. 

Last week these officials tabled their Report from the Commission to the European Parliament, the Council, the European Economic Social Committee and the Committee of hte Regions on the application of Directive 2014/40/EU concerning the manufacture, presentation and sale of tobacco and related products. Despite its long title, this is a relatively succinct (18 page) report which addresses each of the major provisions of the directive and reports on successes and challenges over directive's first 5 years. 

The report recommends that EU parliamentarians strengthen the tobacco directive in support of the public health goal of reducing tobacco use by 30% between 2010 and 2025. It calls for strengthened warning and packaging systems and requirements for plain packaging across the Union. It reports that efforts to reduce the addictiveness and attractiveness of tobacco products through regulation has proven to be complex and costly, and suggests that this goal be reconsidered. It recommends greater efforts to address the use and sale of e-cigarettes, other novel tobacco products, herbal cigarettes and cannabis-based products. It encourages parliamentarians to impose regulatory fees on tobacco manufacturers to finance tobacco regulation. 

On e-cigarettes the Commission reaffirms its belief in of a "careful and precautionary approach". It notes that its scientific body (SCHEER) found the evidence basis for potential harms from e-cigarette use (respiratory and cardiovascular systems, increased smoking by young people, etc) was stronger than the evidence basis for potential benefits (helping smokers quit or cut down). If e-cigarettes are to have a role in cessation, the commission recommends that "their regulation should follow the pharmaceutical legislation."

By their read of the evidence, there is not yet a scientific consensus in favour of e-cigarette use.  "Views on the actual health effects of e-cigarettes are divided, ranging from harmful to harm-reducing for the individual, compared to conventional tobacco products for smoking. As scientific consensus has yet to be reached, the precautionary principle prevails and the TPD takes a careful approach in regulating these products." The further precautions they suggest include "tank size or labelling requirements; use of flavours; use of nicotine-free liquids; and advertising provisions."

The Commission also released the extensive review of tobacco-related developments in the EU which it had commissioned from ICF SA and RAND Europe. This Support study to the report on the application of Directive 2014/40/EU  provides case studies and background information on European tobacco control. The final opinion of the EU's SCHEER committee had been made public last month.

Report of the Royal College of Physicians. (May 20, 2021)

As a consequence of Brexit, Great Britain is no longer bound to follow EU directives on tobacco control, and is in the midst of building its post-Brexit tobacco plan. The U.K. government's tobacco control strategy, released last year, plans to "identify where we can sensibly deregulate without harming public health or where EU regulations limit our ability to deal with tobacco."

To contribute to a new made-in-UK approach, the Royal College of Physicians tasked its Tobacco Advisory Group to make recommendations to government. This group is made up of 16 U.K. tobacco control specialists, drawn from government, university and civil society.

Their report -  Smoking and health 2021: A coming of age for tobacco control? - makes recommendations in several policy areas. These include higher taxes, mass media campaigns, more powerful health warnings, controls on tobacco imagery in films and video games, putting retail shelving out of sight, enhanced monitoring and protection from tobacco industry interference. The advisory group also calls for the National Health Service to further expand its cessation services, and to cover all smokers unless they "opt out".

A key underpinning of  the approach of the RCP's experts is the desire to encourage smokers to quit by switching to e-cigarettes. A number of regulatory steps are proposed to do this, including reducing taxes on vaping products (they are currently subject to the value-added tax), relaxing rules on vaping in public places, publicly-funded mass media campaigns to encourage smokers to switch to vaping, and ensuring e-cigarettes are included in all quit smoking programs. They implicitly exempt vaping products in their calls to increase the age of sale to 21 and to remove  'tobacco' imagery in cultural products. They ask that government review restrictions on e-cigarette advertising and limits on the amount of nicotine permitted in vaping liquids and "to assess the extent to which the regulations support switching from smoking." 

Unlike the experts working for the European Union, this expert group does not see a need for precaution with e-cigarettes. They do not view youth vaping in the United Kingdom as problematic ("while e-cigarettes might lead a small number of young people into smoking, for others, they may displace smoking" ). The conclusions of the Cochrane review in support of e-cigarettes being efficacious cessation aids are satisfactory to them. Other systematic reviews commissioned by government which come to different conclusions are ignored to the extent that they are not identified or cited in this RCP report - including those prepared by the EU SCHEER, the U.S. Preventive Health Services Task Force, the U.S. Surgeon General, and those commissioned by the Australian government,  the Irish government, the Spanish government, and the Netherlands government )

In advance of World No Tobacco Day, the Geneva-based World Health Organization encouraged governments to scale-up their efforts to reduce smoking and provided advice on how they could do so.

The WHO agrees with the Royal College of Physicians that much more needs to be done to reduce tobacco use and that taxes and smoking cessation programs have a major role to play. It differs greatly, however, on the role of e-cigarettes in accomplishing this. "Switching from conventional tobacco products to e-cigarettes is not quitting" ...  "e-cigarettes are not proven cessation aids".

The WHO Director General, Dr. Tedros Adhanom Ghebreyesus portrayed e-cigarettes as an evolution of tobacco industry manipulation of scientific and public opinion and a new wave of harm: "We must be guided by science and evidence, not the marketing campaigns of the tobacco industry – the same industry that has engaged in decades of lies and deceit to sell products that have killed hundreds of millions of people”.

Scientific pluralism and evidence-based policy 

With their contradictory advice on key issues and their inconsistent assessment of the scientific evidence, the reports issued from Europe last week do not simplify the work of health leaders in Canada or other countries. 

In the absence of a scientific consensus, a government's choice of scientific advisors will play a major role in the determination of policy. Notably, three of the ten members of Canada's first Scientific Advisory Panel on Vaping also contributed to the Royal College of Physicians report. With the mandate of this first panel expired, Health Canada is currently striking a new Scientific Advisory Panel. 

This week's reports from Europe are a reminder that the advice Health Canada will receive is highly dependent on its choice of experts.