The importance of cancer plans in the fight against smoking in France

President Emmanuel Macron announced on February 4, 2021 a new strategy to fight cancer in France with the launch of the 4^th "cancer plan". Tobacco is at the heart of this new strategy, one of the objectives of which is to achieve a tobacco-free generation by 2030. The publication of the 4th cancer plan in France comes at a time when the European Union is also committed to such a strategy of a plan to fight cancer. The two plans have similarities with an emphasis on improving smoking prevention. Thus, regulatory tools at EU level will be strengthened to achieve the objective of a tobacco-free Europe by 2040.[1].

Across the 4^th cancer plan (2021 – 2030)[2], France aims to reduce preventable cases by 40% over the next 20 years. Currently, nearly four million people are living with cancer. Annual figures for 2018 show that 382,000 new cases were diagnosed and 157,000 people died from it. The French government will devote €1.7 billion to the cause over the next five years, an increase of 20% compared to the previous period. A strategy associated with ambitious objectives: to reduce, in 10 years, the number of new preventable cancers from 150,000 per year to less than 100,000 and to reduce mortality from the seven most deadly cancers. Nearly half of these preventable cancers - 70,000 - are currently due to tobacco products. In order to reduce this figure, Macron intends to act on increasing the price of tobacco, expanding smoke-free areas, information campaigns on the toxicity of tobacco, and better support for those who stop smoking.[3].

The previous cancer plan - extended by one year in 2020 due to the health crisis - has already had a significant effect on smoking-related cancers in France. The measures implemented during this period from 3^th The cancer plan included the introduction of plain packaging with broader graphic health warnings in 2016, the strengthening of advertising bans for these products, the management of treatment for tobacco addiction and the gradual increase in the price of a packet of cigarettes to reach 10 euros in November 2020. But while the number of smokers in France and the incidence of smoking-related cancers have fallen, 1 in 5 cases of cancer is still caused by smoking each year.

Cancer plans: cornerstones of the fight against tobacco in France

Smoking remains one of the leading causes of illness and premature mortality in France with 75,000 deaths annually, 45,000 of which are from cancer. Since 2002 and the "war on tobacco" declared by President of the Republic Jacques Chirac leading to the adoption of the first Cancer Plan I (2003-2007) and the creation of theNational Cancer Institute In 2004, the fight against smoking was largely structured around these plans. The first cancer plan demonstrated the effectiveness of sustained tax policies in encouraging smokers to quit and dissuading young people from starting. Between 2002 and 2004, the price of tobacco increased by approximately 40%, for a drop in cigarette sales of approximately 25%[4]. In 2003, the first legislation to ban the sale of tobacco products to minors, then limited to those under 16. The country also ratified the WHO Framework Convention on Tobacco Control international treaty in 2004. Based on scientific evidence and proof, this treaty notably made it possible to definitively close a pseudo debate on the toxicity of exposure to passive smoking. Thus, as a result, several countries, including France, revised their current text to better protect against this risk. This is how the Bertrand decree of 2006 which strengthened the terms of application of the smoking ban in all indoor collective use places: public places, workplaces, education, transport. The first measures for the reimbursement, still partial, of tobacco addiction treatments were also taken during this period[5]The implementation of the first cancer plan in 2003 helped reduce tobacco consumption (30% of the population aged over 15 in 2000 to 27% in 2005.

The failure of the fight against smoking during the second cancer plan Cancer Plan II (2009-2013) with a recovery in consumption and prevalence is undoubtedly partly linked to the failure to take into account this priority risk factor that is tobacco in the plan. Some measures were taken such as the extension to 18 years of the ban on the sale of tobacco products to minors, or the affixing of new health warnings, in graphic form Order of April 15, 2010, on the packaging of tobacco products, as well as an initial regulation of flavourings in cigarettes. However, as highlighted by the Court of Auditors' assessment of anti-smoking policies during this period in 2012, there was no coordination, strategy or overall vision in the fight against smoking and essential measures such as tax increases to reduce consumption were non-existent. The results were immediate: the rate of adults smoking daily increased from 27.3% to 29.1% between 2005 and 2010.[6]-[7].

A third cancer plan (2014-2019) was launched on February 4, 2014. Objective 10 of this plan individualizes for the first time a strategy to be defined in the fight against smoking in the plan and thus provides for the implementation of the National Tobacco Reduction Program (PNRT). The latter defines objectives including a reduction of 10% in the number of smokers in 5 years. The PNRT has enabled the establishment of national and regional governance, the renovation of the legal framework on tobacco and the implementation of emblematic actions (plain packaging, enlarged health warnings, expanded right to prescribe nicotine replacement treatments, Month(s) without tobacco or the creation of the tobacco prevention fund).

Encouraging results and the need to continue efforts

After several years of stability, the prevalence of smoking has fallen sharply: one million fewer smokers between 2016 and 2017 and a further drop of 600,000 smokers between 2017 and 2018[8]. The prevalence of daily smoking in 2018 was 25.4%, a decrease of 4 points in two years. The price increase of one euro in March 2018 with a view to a pack costing 10 euros by 2020 marked the government's commitment to massively reduce tobacco consumption and has borne fruit. In 2020, the new figures from the Weekly Epidemiological Bulletin (BEH)[9] highlighted the effectiveness of anti-smoking policies: a decrease in the smoking rate of 1.4 points compared to the previous year: 30.4% smokers, 24.0% daily smokers. This decreasing prevalence remains extremely high, however, particularly in comparison with other countries at the same stage of development of the tobacco epidemic. In addition, there are significant disparities according to social categories. Finally, even if this decline has continued, its intensity has significantly diminished in 2020. The reaffirmation of the objective of a tobacco-free generation by the President of the Republic in connection with the launch of the 4^th The cancer plan seems to be part of this perspective of maintaining a strong policy to achieve the set objectives.

Keywords: Generation Without Tobacco, Macron, Cancer Plans, Anti-tobacco, France, Youth, 2030

[1] Tobacco Free Generation, European Cancer Plan: The Commission for a tobacco-free Europe by 2040, February 4, 2021, accessed February 5, 2021

[2] Decree No. 2021-119 of February 4, 2021 defining the 10-year cancer strategy planned in Article L. 1415-2 1o A of the Public Health Code

[3] Cancer plan: Macron aims for a “tobacco-free generation” by 2030, Le Point, February 4, 2021, consulted on February 5, 2021

[4] Public Health France, What are the anti-smoking measures in France? ? May 20, 2019, accessed February 5, 2021

[5] Aurelie Lermenier-Jeannet, Tobacco in France: a review of the years 2004-2014, Trends No. 92, OFDT, 6 p. May 2014

^[6] Rising tobacco prices cause cigarette sales to drop, l'Express, April 27, 2012, consulted February 5, 2021

[7] GUIGNARD Romain, Beck François, Richard Jean-Baptiste, Peretti-watel Patrick, Smoking in France - Analysis of the 2010 Health Barometer survey, 2014, 56p

[8] Bourdillon F. Editorial. 1.6 million fewer smokers in two years, unpublished results. Bull Epidémiol Hebd. 2019;(15):270-1. http://beh.santepubliquefrance.fr/beh/2019/15/2019_14_0.html

[9] Marques C, Quatremère G, Guignard R, Andler R, Pasquereau A, Nguyen-Thanh V. Focus. French smokers: who are they? Results of the 2017 Public Health Barometer France. Bull Epidémiol Hebd. 2020;(14):291-4. http://beh.santepublique france.fr/beh/2020/14/2020_14_3.html