The unjustified fiscal and regulatory benefits of electronic cigarettes and heated tobacco products in Italy| Tabaccologia

Article

In December 2014, Italy was chosen by Philip Morris International (PMI) for the launch of the first heated tobacco product (HTP): Iqos. This is an electronic device that heats a tobacco stick up to 350 °C to release an aerosol containing some of the toxic substances found in traditional cigarette smoke, including nicotine [1,2]. It is not a coincidence that the industry has chosen Italy as the pilot country in Europe for the launch of their HTP. PMI was well aware that in Italy Iqos would have found fertile ground to obtain very favorable conditions. In fact, due to actions of the industry defined as lobbying [3,4], HTPs in Italy have benefited from a number of facilities compared to traditional tobacco cigarettes. These benefits include in particular the fact that HTPs, not being legally considered as traditional tobacco products, are not subjected to the restrictive rules of the latters, including the absolute ban on advertising and on consumption in indoor public places [1]. Furthermore, HTPs enjoy a very strong reduction in taxation, which has grown up to 75% over time compared to traditional cigarettes. Today in Italy the excise duty for traditional cigarettes is 58%, while that for HTP is 17% [5-7]. Kazakhstan is the only country in the world enjoying a greater tax benefit. The privileges of these products are motivated in Italy by their alleged reduced harm which, however, has never been proven [8,9].

There is no evidence that the use of HTP is effective for quitting traditional cigarette smoking. Indeed, most HTP users are dual consumers (i.e., they also consume traditional cigarettes) [10]. Furthermore, the latest studies, including some conducted in Italy, confirm that heavy smokers who are unable to quit are less interested in trying these products compared to young people, not always smokers, who easily become addicted to nicotine and start smoking traditional cigarettes or relapse [2,8].

It is important to say that in recent years there have been attempts to increase the taxation of these products. Some of those attempts have been proposed by members of the scientific community, motivated by public health interests [11]. Alongside these noble interests, however, there was also strong pressures from some tobacco companies competing with PMI, which pushed for an increase in taxation for purely commercial purposes [12].

Thus, in March 2020, Senator Tommaso Nannicini presented an amendment for the “Cura Italia” decree, with the aim of reducing the tax benefit of HTPs and to finance, with the derived income, home care for people chronically ill, immunosuppressed and those with disabilities [11]. Unfortunately, this amendment was not approved.

In November 2020, in Palazzo Madama, Senator Paola Binetti promoted a press conference on tax increase for HTP (Figure 1) [5,6]. The meeting, moderated by Giulio Valesini, a well-known journalist of the investigative television show Report, compared the initiatives and ideas of several experts in the health and economic field highlighting the many inconsistencies in this area. According to Senator Binetti, “intellectual honesty is needed to recognize that smoking and nicotine seriously harm health even when used in the form of heated tobacco” [5,6].

With the 2021 budget law, it seemed that a crack had reopened on the initiative of parliamentarians from different groups in the Chamber, but yet another opportunity was missed: the tax benefit was reduced by very little (by 5% every year until 2023) [7], and the few financial resources that derive from it have been allocated to finance hundreds of micro interventions. Moreover, as clearly emerged from a Report investigation, by not changing the fiscal policy towards heated tobacco, the Italian state is expected to lose at least 1.2 billion euros in taxes over the next three years due to the lack of equating the excise taxes of HTPs with those of traditional cigarettes.

A similar scenario concerns the electronic cigarettes. In fact, more than ten years have passed since these products have entered the market in Italy. Promoted as less harmful alternatives compared to traditional cigarettes, they soon conquered the market, especially in the first years of commerce [13]. In Italy, electronic cigarettes enjoy practically the same privileges regulating HTPs. As part of the Parliamentary discussion of the Bill 3132 (DL Sostegni-bis), regardless of the scientific evidence supported by studies free from conflicts of interest, some parliamentarians have even proposed an amendment to reduce the already minimal excise duties on refill liquids for electronic cigarettes [14].

As with HTPs, independent researchers are very concerned about the spread of e-cigarettes, especially among young people. The World Health Organization (WHO), in its latest report on the global tobacco epidemic, warned of the dangers associated with the spread of electronic cigarettes [8]. The most important independent scientific societies, including Italian Society of Tabaccology (SITAB), have all sided with the WHO, rejecting the use of electronic cigarettes as possible reduced harm alternatives for smokers as a public health tool [15-17]. However, the situation could be different if the e-cigarettes were used in a specialized anti-smoking setting [18], particularly in specific categories of smokers.

In Italy, we have observed for some years that electronic cigarettes – as well as HTPs – do not contribute to reducing the number of smokers of traditional cigarettes. In particular, in a prospective population study we recently noted how the use of electronic cigarettes increases the risk:

1. of the initiation of traditional tobacco smoking among those who have never smoked;
2. of relapse among ex-smokers;
3. to continue smoking for smokers [19].

So, even without going into the merits of the “safety” of these products, the benefit-risk balance of electronic cigarettes is negative, at least in Italy.

Recently, a group of 100 researchers, who claim to be independent experts on commercial conflicts of interest with the tobacco industry signed a letter supporting harm reduction as a population strategy for tobacco, addressing it to the delegates of the Framework Convention on Tobacco Control (FCTC) who will meet at the Conference of the Parties from 8 to 13 November (COP-9) [20]. These researchers – not all experts in smoking and/or harm reduction and many with conflicts of interest with the tobacco or e-cigarette industry - recommend the use not only of e-cigarettes but also of HTP, also in the absence of a specialized anti-smoking context.

The letter from the 100 researchers goes against the opinion of the WHO, the leading independent experts in tobacco control and the major international associations, to embrace the strategy proposed by the tobacco industry. We recommend the few advocates of harm reduction for tobacco, who are truly independent of conflicts of interest with the industry, to join the WHO and all of us in the fight to: i) ban e-cigarette and HTP advertisements (aimed primarily at young people, certainly not to smokers); ii) prevent the use of these products in public places and workplaces where smoking is prohibited (an activity often carried out by dual consumers, certainly not by those who want to quit smoking); and iii) make a clear distinction between electronic cigarettes and HTPs (the latter to be rejected always and without conditions, since it is still tobacco).

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