Recommendations on Tobacco

Background

t is estimated that between 25 and 30 per cent of all cancers in developed countries are tobacco-related. From the results of studies conducted in Europe, Japan and North America, between 83 and 92 per cent of lung cancers in men, and between 57 and 80 per cent of lung cancers in women, are attributable to cigarette smoking. Between 80 and 90 per cent of cancers arising in the oesophagus, larynx and oral cavity are related to the effect of tobacco, both acting singly and jointly with alcohol consumption. Cancers of the bladder, pancreas, stomach, kidney and cervix are causally related to tobacco Smoking and there have been suggestions of an association with cigarette smoking and an increased risk of leukaemia and colorectal cancer although the causal nature of these latter associations has not been accepted. Because of the length of the latency period, tobacco-related cancers observed today are related to cigarette smoking patterns over two decades ago. Consequently, following any decrease in smoking prevalence there will be a period of time which will elapse before any decrease in the incidence of tobacco-related cancers is apparent.

There is now strong evidence of the adverse health consequences of Environmental Tobacco Smoking (ETS) sometimes referred to as passive smoking. On the basis of the available epidemiological data, the United States Environmental Protection Agency declared in 1992 that ETS was a proven lung carcinogen in humans. The risk of lung cancer is increased in non-smoking women who have husbands who smoke tobacco. There also appears to be an increased risk of myocardial infarction due to exposure to ETS and the adverse health consequences in children whose parents smoke includes an increase in the frequency and severity of asthma.

Tobacco can kill in two dozen ways including causes such as lung cancer and other forms of cancer, heart disease, strokes and chronic bronchitis and other respiratory diseases. Smokers have three times the death rate in middle-age (between the ages of 35 and 69) than non-smokers and about half of regular cigarette smokers will eventually be killed by their habit. Many of these are not particularly heavy smokers but they can be characterised by having started smoking while a teenager. Half of the deaths from tobacco will take place in middle age (35-64) and each will lose approximately 20-25 years of non-smokers life expectancy: the remaining half of the deaths will take place after the age of 70. However, there is clear and consistent evidence that stopping smoking before having cancer or some other serious disease avoids most of the later excess risk of death from tobacco even if smoking stops in middle age.

The European Union is the second largest producer of cigarettes (694 billion in 1993) after China (1,675 billion) and the major exporter of cigarettes (218 billion).

World-wide, smoking kills three million people each year: the second half of the twentieth century was notable for 60 million deaths caused by tobacco world-wide. In most countries the worst consequences of the Tobacco Epidemic are yet to come, particularly among women in developed countries and in populations of developing countries, since by the time the young smokers of today reach middle or old age there will be about ten million deaths each year from tobacco. Approximately 500 million of the world's population today can expect to be killed by tobacco, 250 million of these deaths being premature and occurring in middle age.

The situation in Europe is particularly worrying. The European Union is the second largest producer of cigarettes (694 billion in 1993) after China (1,675 billion) and the major exporter of cigarettes (218 billion). In Central and Eastern Europe there is a continual increase in the smoking habit. Of the six World Health Organisation (WHO) regions, European has the highest per capita consumption levels of manufactured cigarettes and faces an immediate and major challenge in meeting the WHO target for a minimum of 80 per cent of the population to be non-smoking. Currently (Spring 1994) in the European Union, 42% of men and 28% of women smoke. The smoking prevalence in women is artificially reduced by the low rates reported in Southern Europe where there is evidence that those rates are rising and seem set to continue to rise over the next decade. In addition, smoking prevalence in the age group 25-39 years is high (55 per cent in men and 40% in women) and can be expected to have a profound influence on the future cancer pattern. It is especially worrying that the smoking prevalence among General Practitioners, who play an exemplary role in health behaviour, remains high in many parts of Europe. This should be a target for immediate action.

It has been demonstrated that changes in cigarette consumption are affected mainly at a societal level rather than by actions.

It has been demonstrated that changes in cigarette consumption are affected mainly at a societal level rather than by actions, such as individual smoking cessation programmes, targeted at individuals. Actions such as advertising bans and increases in the price of cigarettes have been shown to influence cigarette sales, particularly among adolescents. Therefore, a Tobacco Policy is necessary to reduce the health consequences of tobacco, and experience shows that this should be targeted via a variety of actions aimed at stopping young people starting smoking and helping smokers to quit. To be efficient and successful, a tobacco policy has to be comprehensive and maintained over a long time period. Increased taxes on tobacco, total bans on direct and indirect advertising, smoke-free enclosed public areas, education, effective health warning labels on tobacco products, a policy of low maximum tar and nicotine levels in cigarettes, encouragement of stopping smoking and individual health interventions have to be implemented urgently.

Health maintenance and disease prevention are increasingly important aspects of the work of the General Practitioner and the single most important of these is advice about the health hazards of tobacco smoking.

The importance of adequate interventions is demonstrated by the low lung cancer rates in Scandinavian countries which, since the early 1970s, have adopted integrated central and local policies and programmes against smoking. In the United Kingdom, tobacco consumption has declined by 30% since 1970 and lung cancer mortality among men has been decreasing since 1980 although the rate remains high. In France, between 1992 and 1994 there has been an 8% reduction in tobacco consumption due to the implementation of anti-tobacco measures introduced by the Loi Evin.

Tobacco control remains more than ever an important public health priority. There are various elements to any Tobacco Control Policy but the importance of the medical and oncological community in setting an example is paramount. A particularly fundamental exemplary role is that of the General Practitioner who is so often the interface between the individual and the health services. Health maintenance and disease prevention are increasingly important aspects of the work of the General Practitioner and the single most important of these is advice about the health hazards of tobacco smoking.

Preamble to Recommendations

International medical opinion has favoured market shrinkage by every means available in order to limit the long-term adverse health effects surrounding the use of this product.

Tobacco smoking poses a unique Public Health problem in that if it were discovered today it would automatically be banned. Its ubiquitous usage is an accident of history which cannot be reversed by an unenforceable ban on its use. Initiation into smoking depends on social pressures, while maintenance of the habit depends to a considerable extent on nicotine addiction. Tobacco is manufactured and marketed by an international industry which is overtly committed to market expansion. For several decades, international medical opinion has favoured market shrinkage by every means available in order to limit the long-term adverse health effects surrounding the use of this product. Government action has been remarkably variable on Tobacco Control in marked contrast to the relatively consistent responses to such issues as immunisation. Vigorous Public Health action has reaped rewards in the form of reducing mortality from tobacco-related diseases in some countries, thereby demonstrating that the problem of tobacco use, while slow to respond to control initiative, can be progressively controlled.

...it is not possible to meekly accept the status quo.

Under these circumstances, it is not possible to meekly accept the status quo. The High- Level, Cancer Experts Committee of the "Europe Against Cancer" Programme of the European Commission, has considered the evidence demonstrating tobacco as a cause of premature death from cancer and other serious diseases among citizens of the European Union, together with assessments of the magnitude of the tobacco problem in Europe and elsewhere, to present an alarming situation and a continuing serious hazard to Public Health. The recommendations outlined below, presented in no order of priority, reflect this view.

Recommendation

The High Level Cancer Experts Committee of the "Europe Against Cancer" Programme of the European Commission (hereafter referred to as the Cancer Experts Committee), taking into account the advice of the Helsinki Tobacco Consensus Conference, unanimously recommends to the European Union that measures to reduce Tobacco Consumption be the top health priority for the European Union for the quinquennium 1997--2001.

Recommendation

The Cancer Experts Committee considers that there is no rationale for the promotion of a known carcinogen by any means, direct or indirect. It therefore recommends in the strongest possible terms that the measures, relevant to this issue, already agreed to by the European Parliament be implemented without delay. There is widespread agreement among health education authorities that tobacco advertising plays a role in encouraging the uptake of smoking and should be banned.

Recommendation

Historically, the composition of the cigarette, unlike any other marketed poison, has been basically unregulated. In recent years some limits have been recommended or mandated for tar and nicotine contents of cigarettes. Manufacturers are nevertheless allowed to introduce additives without demonstrating their freedom from toxicity either before or after combustion. Government Departments have avoided taking responsibility for authorising the inclusion of substances to a mixture which changes upon combustion and is carcinogenic. They have had no qualms about controlling manufacturers of diverse agents including antibiotics and soft drinks by formal regulation.

Therefore, the Cancer Experts Committee recommends that cigarette content should be the subject of regulation throughout the European Union. From 31st December 1997 onwards:

(i) Only tobacco, tobacco paper, filter materials and tobacco extracts should be permitted in cigarettes sold or manufactured in the European Union. Any additives to be included should be demonstrated free of toxicity and other harmful effects on health, in burnt and unburnt form. Additives to cigarettes should be monitored and included on the labelling as with other drugs and foodstuffs on the market. The tar content of cigarettes should be limited to a maximum of 12mg as currently mandated for 31st December 1997. The nicotine content of cigarettes should be limited to 1mg from 31st December 1997.

(ii) The maximum allowable limits of the tar (12mgs) and nicotine (1mg) contents of cigarettes sold or manufactured in the European Union should be decreased by 10 per cent each year until levels of 5mgs tar and 0.5mg nicotine are met.

(iii) By 31st December 1997, labelling requirements similar to those currently applicable in Australia should be in force. In particular, the health warning should be strengthened, made more prominent and the labelling should include a toll-free, telephone number from which accurate information about smoking, its health consequences and smoking avoidance can be obtained. By 31st December 2000, generic packaging of cigarettes and tobacco products should be mandatory.

Recommendation

The Cancer Experts Committee notes that smoking begins in adolescence or earlier and that reduced availability is an anti-smoking influence. On this basis it is recommended that steps should be taken aiming to reduce the availability of tobacco products to children and adolescents. Self service displays and vending machines should be withdrawn.

Recommendation

In the light of evidence that price increases are a deterrent to smoking, have a greater effect on children and, further, that regular price increases are necessary to maintain the effect, the Cancer Experts Committee recommends that the European Union pursues a tax policy aimed at the upward harmonisation of the retail price of tobacco products

Recommendation

Regardless of the right of the smoker to smoke, non-smokers have the right to breathe air that is as unpolluted as possible. Pollutants such as asbestos and benzene are limited by law to the lowest practical level attainable. The lowest level attainable of tobacco smoke is zero. While cancer risk is not perhaps as immediate as that of triggered asthma attacks, orthodox Public Health practice requires that non-smokers be protected from tobacco smoke in the workplace and public places in the broadest sense. The common-sense of this recommendation is emphasised by various legal precedents which show that employers in some countries are vulnerable at law for breach of the elementary requirement to provide a safe workplace.

To protect the rights of non-smokers and prevent involuntary exposure to environmental tobacco smoke, the Cancer Experts Committee recommends that smoking be banned in public places and in the workplace. Separate smoking sections may be introduced in the workplace, and in places such as restaurants and bars. Smoking should be prohibited on air flights within the European Union.

Recommendation

The Cancer Experts Committee considers there is a clear and obvious need for comprehensive education programs to inform professionals, the public and children of the dangers of smoking, as well as to explain the rationale for the anti-smoking measures recommended here. Education programmes obviously need to be culture and language specific.

With this in mind the Cancer Experts Committee recommend the following general proposals, aware that some have already been adopted and implemented by the European Commission in the context of the on-going "Europe Against Cancer" Programme;

That each country be encouraged to form a coalition of groups involved in public health and education to be charged with organising appropriate national programmes whose principal aim is to initiate action to reduce tobacco consumption and its serious effects.
That national groups be encouraged to join in a Europe-wide collaborative network aimed at sharing information and expertise.
That the European Commission continue to sponsor regular, at least annual, meetings of this collaborative network.
That relevant public health/education/behavioural research be a function of the national and European groups.
That surveillance and monitoring of education programmes, behavioural trends, smoking prevalence, knowledge and relevant attitudes be a priority and be funded as part of the comprehensive programme.
That programmes directed specifically at health professionals be supported and further developed in those countries where smoking prevalence is high in these groups.
That there be a designated centre whose objectives should include the continual evaluation of the scientific literature of the association between tobacco usage and disease and the patterns of tobacco-related disease within the European Union. This Centre should be mandated to prepare an Annual Report for submission to the European Parliament.

Recommendation

The Cancer Experts Committee welcomes the phasing out of the sale of duty free cigarettes and other tobacco products. n

Smoke Free Europe - A Forum for Networks - 14 AUG 1997

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