The OECD report on the evaluation of the national tobacco control programme in France| Tabaccologia

Abstract

In France, tobacco smoking caused 13% of all deaths in 2015 and its consumption is one of the main causes of non-communicable diseases. Therefore, France implemented a significant tobacco control programme from 2016 to 2020, including a 41% increase in taxation of tobacco products, the implementation of plain packages for cigarettes, the full refund of nicotine substitutes and the smoking cessation campaign called #Mois- SansTabac. This programme had a positive effect reducing smoking prevalence by 5 percentage points from 2016 to 2019, with a partial increase during 2020, likely associated to the COronaVIrus Disease (COVID-19) pandemic. The Organisation for Economic Cooperation and Development (OECD) assessed the health and economic impact of the national tobacco control programme, considering its continuation in the period 2023-2050. The programme would allow to avoid 4 million of new cases of smoking attributable diseases and it would extend healthy life expectancy by 1.5 months per person in the whole French population. Furthermore, it could reduce healthcare spending by €578 million per year, with a return on investment of €4 for every invested euro. These data provide a useful framework for the adoption of measures to end smoking and France ambition is to have the first generation of non-smoking adults by 2032.

Introduction

In France, tobacco caused 75,000 deaths in 2015, representing to 13% of all deaths [1], despite tobacco control measures adopted in 1991 [2]. Its consumption is one of the main causes of chronic diseases, such as cancer, chronic obstructive pulmonary disease (COPD), and cardiovascular diseases. Although the prevalence of smoking has decreased over the years, in 2021 it was among the highest in the countries belonging to the Organisation for Economic Co-operation and Development (OECD), with high prevalence among young people and women [3].

The OECD, an international organisation dedicated to developing policies for a better life, recently published a paper evaluating the national tobacco control programme in France [3]. The paper aims to analyse the effectiveness of the French smoking cessation campaign implemented from 2016 to 2020 by estimating the economic and health consequences of extending it to 2050.

The tobacco control programme

The law of January 10, 1991 relating to the control of smoking and alcoholism (Évin law), which halved tobacco sales in France, is the cornerstone of France’s anti-smoking policy [2]. Launched in 2014, the National Tobacco Reduction Program (PNRT) 2014-2019 [4], continued by the National Tobacco Control Program 2018-2022 (PNLT) [5] has established national and regional governance of tobacco control, renovated its legal framework and enabled actions. From 2016 France implemented a significant anti-smoking programme [3] including:

1. an increase in taxation levels on tobacco products, resulting in price increases spread over three years. The price of the best-selling package of cigarettes increased from €7 in 2017 to €10 in 2020, an increase of 41%, the highest price increase in France in 20 years;
2. the introduction of the plain package for traditional cigarettes;
3. the reimbursement of nicotine substitutes: the annual flat-rate reimbursement of €150 per smoker has been replaced by a reimbursement of the full amount spent;
4. a campaign to promote smoking cessation (#MoisSansTabac), organised every year in November since 2016, with the aim of mobilising smokers who want to quit and supporting them in their activity with encouraging messages on social networks, self-help groups and awareness-raising activities at the local level.

The programme is believed to have had a significant impact on public health and healthcare expenditure. In fact, already in the first year of the implementation of the campaign, data from the Health Barometer (an annual representative survey of the French population [6]) showed a reduction in the prevalence of daily smokers from 29.4% in 2016 to 26.9% in 2017, i.e. a drop of 1 million fewer smokers in one year: an undoubtedly considerable achievement [7]. This decline was stronger among young people aged 18 to 24, among women aged 55 to 64, and among those with lower levels of education and income [7]. Considering all smokers, both occasional and daily, between 2016 to 2019, the prevalence of smoking in France fell by 5 percentage points, from 35% in 2016 to 30% in 2019 [3].

The effect of COVID-19

In contrast to previous years in which the tobacco control programme was effective and tobacco sales decreased, the COronaVIrus Disease (COVID-19) pandemic also had an impact on smoking prevalence, which shifted and increased again between 2019 and 2021, reaching 32%, particularly among women [3]. This trend could be interpreted as an effect of the many events and factors that influenced lifestyles during the pandemic, such as fewer quit attempts and increased tobacco consumption among smokers. Women, young people and remote working graduates were the population groups most likely to increase their tobacco consumption during lockdowns, while older people, in contrast, were the most likely to try to quit smoking.

Moreover, after stabilizing during the COVID-19 pandemic due to the restrictive measures, the illegal tobacco market increased again during 2021. Through the cross-border trafficking from Spain and Andorra to south-western France, and from Belgium and Luxembourg to northern France, large-scale trafficking is reaching the level of drug trafficking. Tobacco comes from Eastern Europe, North Africa and China via transport companies, then is distributed throughout the country. In 2021, over 400 tons of contraband tobacco were seized, which is probably only a small proportion of the total contraband tobacco [8].

The OECD simulation model

The OECD set out to assess the health and economic consequences of the tobacco control programme using a microsimulation model (called SPHeP-NCD), an advanced modelling tool for public health policy and strategic planning systems. The model covers 52 countries and, for each, apply the demographic characteristics and risk factors of age and sex specific populations from international databases. Based on these characteristics, an individual is associated with a percentage risk of developing a certain disease each year. For this assessment, an ad hoc module has been added to quantify the relationship between current and past tobacco consumption (duration and number of cigarettes smoked in pack/year, as well as the time elapsed since smoking cessation), and the risk of developing diseases.

The aim is to assess the health and economic impact of the national tobacco control programme 2016-2020, projecting its continuation in the period 2023-2050. According to the simulations developed, tobacco control, if maintained, will have significant positive effects in France in the coming years:

1. It will prevent 4 million new cases of disease between 2030 and 2050, including 1.87 million musculoskeletal disorders, 1.54 million lower respiratory tract infections, 0.3 million COPD, 0.2 million smoking-related cancers, 0.1 million cardiovascular diseases and several hundred cases of dementia and diabetes. In relative terms, this represents 5.5% of COPD cases and 3.4% of smoking-related cancers.
2. It will increase life expectancy by 1.3 months and healthy life expectancy by 1.5 months over the period 2023-2050. These gains are calculated for the whole population, and are therefore likely to be greater for smokers. By way of comparison, life expectancy in France has increased by about 6 months for women and 11 months for men over the last 10 years.
3. It will reduce health spending by €578 million per year, or 4% of France’s spending on preventive medicine in 2016. This reduction in expenditure does not take into account the state’s revenue from the approximately €3 per package increase in tobacco taxation foreseen in the programme, estimated at over €9 billion per year.
4. If health spending is taken into account, there would be a positive economic return. In fact, the cost of the #MoisSansTabac campaign is estimated at €12.5 million per year, based on data provided by the French Public Health and the cost of reimbursing nicotine substitutes amounts to approximately €132 million per year based on sales. The cost of taxation on smoking products is estimated at approximately €3.4 million and includes administration, planning, monitoring and enforcement activities at national level. The cost of the plain package is close to zero, as the expenditure is not borne by the government. The total implementation cost of the package is estimated at €148 million per year and is exceeded in the long run by savings in health expenditure with a return on investment of €4 for every euro invested.
5. It will have a positive impact on productivity and labour market participation, increasing the full-time working population by 19,800 persons per year. This increase would be due to a decrease in absenteeism and a decrease in early retirement. Expressed in monetary terms using average wages, the improvement in productivity and labour market participation would generate a gain of €18 per person per year, equivalent to €715 million per year at the population level.
6. Despite the significant improvements achieved by this tobacco control programme, tobacco will continue to be a major health and economic burden for years to come. Its complete elimination would produce even greater health and economic results, despite longer life expectancy, an increase in the number of elderly people and, consequently, an increase in the number of ill people in this population group and related medical costs. More specifically, without tobacco, more than 25 million cases of chronic disease could be avoided between 2023 and 2050, and the decrease in healthcare expenditure would represent up to 3% of the annual healthcare budget.

These data provide a useful framework and support for the adoption of measures to stop smoking and, in this context, France’s ambition is to have its first generation of non-smoking adults by 2032.

Focus: electronic cigarettes

Although the document focuses mainly on the use of traditional cigarettes, some data on the use of electronic cigarettes (e-cigs) are also presented. In 2021, 38.7% of French adults (18-75 years old) tried e-cigarettes and 5.0% used them daily. The trend towards exclusive use of e-cigarettes is increasing among adolescents (from 5.1% in 2018 to 8.0% in 2021) and these new devices are also used by smokers trying to quit smoking. However, it should be noted that, according to the World Health Organisation, the potential role of e-cigarettes in smoking cessation remains unconvincing and their use has increasingly proven negative effects, particularly on cardiovascular health. Furthermore, in France in 2021 the High Council of Public Health stated that the scientific evidence for proposing e-cigarettes as an aid to smoking cessation by health professionals is currently insufficient [9].

References

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