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Up in smoke: How Belgium regulates e-cigarettes and alternative tobacco products
Alternative nicotine products like e-cigarettes can play an important role in helping Belgian quit smoking, says the country’s superior health council’s new advisory report.
But non-smokers and youngsters should not start using vaping products, recommends the council, seven years after its first study into the pros and cons of the growing alternative nicotine market.
While this earlier report recommended that the same rules for cigarettes be applied to heated products, after two years of investigation, there’s now a more positive, albeit vigilant message. It finds that e-cigarettes are clearly less harmful than smoking and can play a positive role in helping smokers quit. It cites, in particular, the potential benefits for vulnerable and disadvantaged groups in the population.
By underlining that the majority of risks from smoking cigarettes stem from toxic substances released by the combustion of tobacco rather than nicotine, the council endorses different rules for vaping. It also calls for clearer information because of the perceived risk surrounding alternative products.
Despite the known harms, smoking remains the world’s biggest public health threat with an estimated 1.3 billion people globally using tobacco products. It’s also of significant concern in the EU, where 26% of the adult population and 29% of young Europeans aged 15 to 24 smoke.
In response to the ongoing global health crisis, western countries adopt varying stances. The UK and New Zealand aim to go smoke-free before the end of the decade, with England considering becoming the first country in the world to prescribe medically-licensed e-cigarettes in ambitious targets to curb smoking.
New Zealand’s bolder policies include outlawing smoking for the next generation by banning anyone born after 2008 from legally buying cigarettes. The government’s Smokefree Aotearoa 2025 Action Plan aims to reduce smokers in the country to 5%, assisted by vaping and smoke-free products.
Sweden and Norway have embraced the alternative tobacco market. With only 5% of its population smoking, Sweden has the lowest smoking rates among men in Europe. The country has a long tradition of using Snus, a reduced-harm nicotine product that’s banned from sale in the EU, except in Sweden.
Also turning to smoke-free products is the Czech Republic. It’s currently preparing legislation to include nicotine pouches and reduced-risk policy tools in its public health strategy, which would make it the leading proponent of tobacco-harm reduction in the EU.
Smoking rate in Belgium remains too high
In Belgium, where some 1.4 million people smoke daily and more than 360,000 smoke occasionally, the health council recognises that the decline in smoking prevalence rates is too slow. It recommends that the sale of tobacco should gradually be phased out in favour of selling e-cigarettes. The goal is to help smokers quit via ‘time limited’ vaping, while not compromising on the protection of non-smokers.
But in banning nicotine pouches, among other smoke-free products, Belgium is “missing out” on the safest possible alternative to cigarettes, says Clive Bates, an independent tobacco harm reduction advocate.
“It needs to see the bigger picture, allow these products in the market and let them benefit consumer choice to reduce the burden of smoking and smoking-related diseases,” adds the former director of Action on Smoking and Health in the UK.
He defends harm reduction policies as a legitimate and sound public health strategy with a proven track record in diverse areas such as sexual health and car safety. “We’ve got 8 million people according to the World Health Organisation dying every year from smoking, we’ve got targets to achieve and all of them will be missed because they’re not really embracing what is an easy and good pathway out of smoking.”
It’s easier to switch from smoking to vaping or smoking to non-tobacco products than to go from smoking to abstinence, points out Bates. In addition to the health benefits of tobacco alternatives, the incentive for smokers to change their behaviour is the immediate improvement in their wellbeing. “They can breathe more easily, they’re coughing less and more able to participate in physical activity.”
Lifting the stigma around smoking and decreasing the economic burden are additional advantages for addicts. “As a bonus, their long-term health prognosis and life expectancy has improved. Everyone should wake up in public health and think that’s a result. We should be achieving this in millions of cases and if we can do that, we can basically make the cigarette obsolete.”
But nicotine addiction is another matter, says Bates, recognising that demand for the stimulant has been around for a long time and is likely to persist. “Stripped of the smoke, it’s not a particularly harmful drug and doesn’t cause cancer or cardio-vascular disease.” While not completely benign, nicotine doesn’t cause oblivion, loss of control or intoxication and does help people deal with stress and anxiety, he adds.
Tobacco at the centre of an ideological battleground
Tobacco harm reduction as a policy remains controversial. Promoting ‘safer’ nicotine alternatives continues to draw critics, even though it’s an approach successfully applied to other fields and industries.
With new nicotine products representing a significant market of almost €10 billion worldwide, some tobacco companies have committed to a smoke-free future. Philip Morris International (PMI) is a global player that’s in the process of switching to alternatives.
“We’re the only company to go all-in, wanting to replace all cigarettes with smoke free products as soon as possible,” explains global vice president international communications Tommaso Di Giovanni. The company has invested over $9 billion in the last decade, aiming to reach its target of 50% of sales from alternative products by 2025 (smoke-free revenues currently account for 31%).
Investments have been ongoing into science and technological research to develop new combustion-free alternatives. After launching in Japan and Italy in 2014, its flagship product IQOS is now sold in 71 different countries (excluding Russia and Ukraine), with more than 15 million adults making the conversion.
The heated tobacco device isn’t available in Belgium due to the country’s concern over potential long-term health risks and its legislation on alternative products. For Di Giovanni, IQOS exemplifies the balancing act that characterises tobacco harm reduction, offering “a sensory experience” that appeals to smokers, while reducing the number of harmful compounds.
“In 10 to 15 years we may remember cigarettes as something from the past in countries where the governments, NGOs and public health community are heading in the same direction,” he says, calling for a pragmatic logic to be applied tobacco and nicotine in a similar vein to electric cars.
But doesn’t increasing tax on cigarettes reduce smoking prevalence? “You can do both,” he insists. “Countries that apply both measures have the best success in reducing the rate of cigarette use.” He points out that Japan and South Korea have witnessed improvements in public health due to adopting smoke-free products and recognising the tobacco harm reduction concept.
The UK is another example, he says. “In the seven years since they adopted e-cigarettes, smoking incidence decreased by 28%.” As for New Zealand’s aim to become smoke free by 2025, “it encourages as many people as possible to quit smoking or not to start, but they created a different regulatory approach to products that are non-combustible, while maintaining a proactive campaign to encourage smokers to switch to smoke-free alternatives.”
Meanwhile, Belgium has 27% of its population smoking, 20% if you take the number of people smoking daily, says Di Giovanni, quoting 2021 figures from the Cancer Foundation. “In 2011, it was 26 to 27%, which means that smoking has decreased by one point every year. But the impact of traditional tobacco control policies is decreasing.”
He alludes to France’s 40% illicit cigarette trade being the result of taxes rising above a certain threshold. “Excessive taxes do not work,” he says, comparing the country to Japan, where “since the introduction of heated tobacco products in 2014, the decline in the sale of cigarettes has been 44%, five times faster than before the adoption of these products”.
Can he appreciate the distrust around tobacco companies’ new zeal for harm reduction? “It’s easy to say the company is responsible for the use of the product but cigarettes existed before us and burned tobacco is as old as humankind. You can look at the glass half full and say tobacco companies are doing an extraordinary amount in advancing technology, to the extent that PMI’s transformation is based on science, and we’re doing it to address a big societal issue caused by smoking.”
Belgium’s health council is one of many worried that alternative products could introduce youngsters to smoking. “It’s a fair concern,” he responds. “But out of fear of something, you stifle innovation, you don’t allow adult smokers to have access to these products.”
He invokes data from the US Food and Drug Administration that reported little interest from youth and non-smokers in heated tobacco products. Research in Germany, Switzerland and Japan also showed that interest in IQOS was limited, adds Di Giovanni. “Let’s monitor it and if necessary take corrective action. The products aren’t designed to attract youth or non-nicotine consumers.”
If committed smokers need to be reminded that quitting remains the best health option, they also deserve to know more about the risks and benefits of alternatives, he says. “If you don’t quit and don’t receive information about alternatives, you’re going to continue using cigarettes, probably thinking that smoke-free products are as bad as cigarettes, and that’s counter to any public health interest and the health interests of the smoker.”
Photos: Goodboro e-cigarette, e-liquids & accessories store, Namur © Damien Maguire/Image Digital