Taking the E-asy path: E-cigarettes not the only option to address tobacco harms

Posted on by BMJ

May C.I. van Schalkwyk

Department of Primary Care and Public Health, Imperial College London.

m.van-schalkwyk@imperial.ac.uk

There has, and continues to be, much debate about the stance taken by some organisations in the United Kingdom (UK) on the role of e-cigarettes in the battle to avert the unparalleled harm caused by the consumption of tobacco products. The recent publication of a report on e-cigarettes by the House of Commons Select Committee on Science and Technology has focused a spotlight on the issue.1

The debate has attracted particular interest as authorities in England (but not the rest of the UK) have, almost uniquely internationally, strongly endorsed e-cigarettes, arguing that they are a means to help smokers quit and an opportunity to save lives.2 Authorities in other countries have taken a much more cautious approach, questioning the effectiveness and safety of e-cigarettes based on the limited evidence available.

What is especially perplexing is that the debate in England is so focussed on these products, almost as if there were no other options available. Even if those promoting e-cigarettes do not believe this, the attention being given to them certainly distracts attention from the other options. So why is this individualised approach with a new and unproven technology being pursued to address one of the nation’s greatest public health threats and why, at least in popular discourse, does it seem to be portrayed as the only route available? This question becomes particularly important given the prominence of the tobacco industry in the oral evidence invited by the Committee, to the surprise of the international tobacco control community who thought that such engagement is now precluded by the World Health Organisation Framework Convention on Tobacco Control, to which the UK is a signatory, and which is meant to exclude the industry from the policy making process.

One critical issue that does not appear to have surfaced in the latest discussions is why effective, cost-effective, and safe measures already available, if not already in place, are not being reviewed, enhanced, and delivered in a way that maximises their impact as tobacco control interventions. The most effective measures act at a population rather than an individual level and tackle price, availability, and marketing. Price is typically targeted by tobacco excise taxes. Raising the prices of tobacco products by increases in tobacco taxes is one of the most effective tobacco control measures, and is a key component of the Framework Convention on Tobacco Control.3–7 Continued tax increases, year after year, have many benefits, reducing smoking prevalence, consumption, and initiation and are one of the few interventions shown to reduce smoking inequalities.4,8–12

Tobacco tax revenues can also be used to cover the cost of other tobacco control or health measures.5 The impact of taxes has been shown to be enhanced by the presence of other tobacco control measures such as awareness campaigns and cessation services.13 At present, however, the debate seems to be centred on the taxation of e-cigarettes and how best to approach this. What should also feature prominently in the discussion is how to improve the current tax regime for traditional tobacco products, a measure that the evidence suggests is likely to have profound impacts for health. As shown by UK researchers, current government tax policy is undermined by the tobacco industry through their adoption of various pricing strategies.14,15 These strategies include differences in how tax increases are fed through to different segments of the market, i.e., the added price due to taxes are passed onto expensive cigarettes while with cheap products the manufacturers absorb them, protecting those products which appeal to the poorest so their prices remain low or even reduce with time. Pervasive gaps remain between expensive and cheap tobacco products, with roll-your-own (RYO) tobacco being sold at a fraction of the cost of expensive cigarettes, a phenomenon seen across the EU including the UK.14,16,17 Availability of lower cost products undermines the impacts of tax increases in preventing initiation and in supporting quitting.18,19 In addition, lack of large scale awareness campaigns means harmful misbeliefs about the safety of RYO compared to manufactured cigarettes continue to held.20

While action has been taken to address these issues there is still so much more that can be done, such as consideration of minimum pricing laws or price caps.21,22 All of these options are evidence-informed and also support the tobacco endgame agenda. We need to use what works to set people free of an addiction, and prevent others from ever becoming so, by creating environments and systems that sever ties with nicotine in all its forms.

There is so much that can be done to address tobacco control in the UK and beyond using evidence-based and safe measures that simply need to be implemented effectively to maximise their impact. It seems only reasonable to try this route before taking people down an unknown path with limited understanding of where it will lead us.

References:

  1. E-cigarettes – Science and Technology Committee – House of Commons. https://publications.parliament.uk/pa/cm201719/cmselect/cmsctech/505/50502.htm. Accessed August 19, 2018.
  2. Government missing opportunity with e-cigarettes – News from Parliament – UK Parliament. https://www.parliament.uk/business/committees/committees-a-z/commons-select/science-and-technology-committee/news-parliament-2017/e-cigarettes-report-publication-17-19/. Accessed August 19, 2018.
  3. Bank TW. Curbing the epidemic: governments and the economics of tobacco control. The World Bank. Tob Control. 1999;8(2):196-201.
  4. IARC Handbook of Cancer Prevention Volume 14 – Effectiveness of Tax and Price Policies for Tobacco Control. Lyon, France; 2011. http://www.iarc.fr/en/publications/pdfs-online/prev/handbook14/index.php. Accessed August 7, 2018.
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  7. Chaloupka FJ, Straif K, Leon ME, Working Group, International Agency for Research on Cancer. Effectiveness of tax and price policies in tobacco control. Tob Control. 2011;20(3):235-238.
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  12. Wilson LM, Avila Tang E, Chander G, et al. Impact of Tobacco Control Interventions on Smoking Initiation, Cessation, and Prevalence: A Systematic Review. J Environ Public Health. 2012;2012:1-36.
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  14. Hiscock R, Branston JR, McNeill A, Hitchman SC, Partos TR, Gilmore AB. Tobacco industry strategies undermine government tax policy: evidence from commercial data. Tob Control. October 2017:tobaccocontrol-2017-053891.
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  16. Partos TR, Gilmore AB, Hitchman SC, Hiscock R, Branston JR, McNeill A. Availability and Use of Cheap Tobacco in the United Kingdom 2002–2014: Findings From the International Tobacco Control Project. Nicotine Tob Res. 2018;20(6):714-724.
  17. López-Nicolás Á, Stoklosa M. Tax harmonisation and tobacco product prices in the European Union, 2004–2015. Tob Control. August 2018:tobaccocontrol-2018-054342. doi:10.1136/TOBACCOCONTROL-2018-054342.
  18. Ross H, Blecher E, Yan L, Hyland A. Do cigarette prices motivate smokers to quit? New evidence from the ITC survey. Addiction. 2011;106(3):609-619.
  19. Hyland A, Higbee C, Li Q, et al. Access to low-taxed cigarettes deters smoking cessation attempts. Am J Public Health. 2005;95(6):994-995.
  20. Brown AK, Nagelhout GE, van den Putte B, et al. Trends and socioeconomic differences in roll-your-own tobacco use: findings from the ITC Europe Surveys. Tob Control. 2015;24 Suppl 3(Suppl 3):iii11-iii16.
  21. Huang J, Chriqui JF, DeLong H, Mirza M, Diaz MC, Chaloupka FJ. Do state minimum markup/price laws work? Evidence from retail scanner data and TUS-CPS. Tob Control. 2016;25(Suppl 1):i52-i59.
  22. Gilmore AB, Branston JR, Sweanor D. The case for OFSMOKE: how tobacco price regulation is needed to promote the health of markets, government revenue and the public. Tob Control. 2010;19(5):423-430.

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