Tobacco control in cancer prevention

February 8, 2022

Par: National Committee Against Smoking

Dernière mise à jour: August 6, 2024

Temps de lecture: 23 minutes

Translation of the Smoke Free Partnership information document

smokefree-partnership-cancer-tabac

The Coalition Smokefree Partnership (SFP) is a network of independent European and national advocacy organisations with technical expertise in tobacco control policy. The coalition partners work together to promote and support tobacco prevention by developing advocacy for European tobacco control policies through the development and implementation of the FCTC, its protocols and guidelines.

I. Introduction

II. Tobacco consumption and cancer risk

III. Anti-tobacco control, an essential pillar for effective cancer prevention

IV. Comprehensive Policies for Tobacco Control

V. Smoke Free Partnership policy recommendations for the European Plan to Beat Cancer

VI. Importance of public health research for tobacco control

Introduction

Tobacco is the biggest risk factor for cancer and non-communicable diseases (NCDs), but also the most preventable. Cancers cause 26% of all deaths in the EU and are the second leading cause of death (after cardiovascular diseases which account for 36% of all deaths in the EU).^[1]Smoking is responsible for around 1 in 7 deaths in the EU, including 22% of all cancer deaths and 10% of cardiovascular disease deaths.^[2] Effective tobacco control measures could, in the long term, eliminate up to 90% of current lung cancers.^[3]

The fight against NCDs is part of the global effort through the Sustainable Development Goals (SDGs), through target 3.4 asking all countries to "reduce by one third, through prevention and treatment, the rate of premature mortality due to non-communicable diseases"The Sustainable Development Agenda recognizes tobacco control as a key enabler to achieve this goal through SDG target 3.A calling for “ Strengthen implementation of the World Health Organization Framework Convention on Tobacco Control in all countries". The global NCD targets commit all countries to reduce tobacco use by 30 % among all people aged 15 years and older by 2025. On current trends, only 6 EU countries will meet this target.^[4]

The fight against cancer has been on the EU political agenda for three decades. Multiple policy and legislative initiatives have enabled considerable progress in reducing the number of cancers in European countries. Tobacco use has been listed in the European Code Against Cancer since its inception, as the leading preventable cause of cancer. One of the main priorities on the European Commission's agenda for the 2019-2024 mandate is to contribute to Europe's fight against cancer.

In 2019, the European Commission announced a mission on cancer in its research agenda and committed to developing a comprehensive European Beating Cancer Plan within the first year of its mandate. These commitments were adopted at the highest political level and received the full support of the President of the European Commission, the Vice-Presidents and the Commissioner for Health. This initiative was one of the flagship issues of the 2019 European election campaign for the current Commission.

Tobacco control is based on a strong scientific consensus on both the risks of tobacco use and the positive impact of tobacco control measures. Beyond this, public opinion data demonstrate that the EU population supports tobacco control measures such as plain packaging, advertising bans and other tobacco control measures.^[5]

Tobacco use and cancer risk

In recent years, the effectiveness of cancer care has improved and overall cancer survival rates have reached record highs.^[6] However, the increasing incidence of cancer cases and deaths remains a widespread concern, and more attention needs to be paid to prevention. Tobacco use remains the primary and most important risk factor for cancer,^[7] and responsible for more than 22,100 cancer-related deaths worldwide.^[8] ^[9]

In the EU, up to 9 out of 10 deaths from cancer of the trachea, bronchi and lung are linked to tobacco consumption.^[10] Smokers are 8 to 10 times more likely to die from lung cancer than non-smokers.^[11]

Tobacco use is responsible for increasing the risk of developing 16 types of cancer,^[12] It is notably the main risk factor for the development of lung, trachea, bronchial and oral cancer,^[13]-^[14] or even the colon.^[15] More specifically, in the EU, where smoking is the main risk factor, lung cancer is the leading cause of death among men (25% of all cancer deaths) and is the second leading cause of death among women.^[16] In the EU, lung cancer accounts for around 273,000 of the 1,320,000 deaths (21%) caused by cancer in 2015.^[17] In addition, tobacco use increases the incidence of cancer relapse and recurrence.^[18]

Despite a decline in smoking prevalence in recent years, in the EU, 26% of adults and 29% of 15-24 year-olds smoke,^[19] These rates are the second highest in the world after the prevalence in the EURO region.^[20] The EU has a low gender disparity in tobacco consumption (30% men, 22% women),^[21] and 9 out of 10 smokers in Europe are daily users.^[22] Among smokers in the EU, 93% started smoking before the age of 25.^[23]

Exposure to second-hand smoke significantly increases the risk for non-smokers and children of developing cancer and increases the risk of developing lung cancer by 20 to 30%.^[24] Children and babies are also vulnerable to third-hand smoke, which contains lingering smoke and cigarette residue and particles.^[25]

Socioeconomic and gender gaps in tobacco use and cancer development are ongoing concerns.. For example, the EU has seen a significant increase of 20% in lung cancer rates over the past decade, driven by an increase in the number of women affected by the disease.^[26] This factor can be explained by the increase in smoking rates among women, several decades after men, which generates a gender gap in cancer prevalence as well as an ever higher prevalence for men.^[27]

Anti-tobacco control, an essential pillar for effective cancer prevention

Prevention is essential focuses on a population approach, targeting environmental conditions, reducing exposure to risk factors (eg: advertising for tobacco products) as much as possible.^[28] Primary prevention involves eliminating or reducing exposure to recognized risk factors in populations to prevent disease before health effects occur through measures (e.g., smoking cessation) that alter risk behaviors.^[29] Primordial prevention and primary prevention are important means for improving public health and are cost-effective in reducing the economic burden of cancers and NCDs worldwide.^[30]

Prevention (especially primary prevention) is a key factor in reducing the number of cases and deaths from cancer and other non-communicable diseases (NCDs).

Effective prevention must include proven, cost-effective tobacco control measures enshrined in the WHO Framework Convention.

European and national policies and measures to end tobacco use should target the initiation of tobacco use among young people as well as effective smoking cessation programmes.

Effective prevention focused on tobacco control would help reduce or eliminate:

Deaths and suffering caused by cancer:

Approximately 90% of lung cancers are attributable to smoking,^[31] thus, they could be eradicated by stopping tobacco use. Deaths from other types of cancers identified as linked to tobacco use could also be limited;
In addition to saving human lives, effective prevention would also benefit general human well-being and improve long-term health by avoiding symptoms and pain as well as the physical and mental suffering endured by cancer patients and their families.^[32];
Smoking cessation is beneficial for primary disease prevention (prevention before health problems occur), secondary prevention (prevention after diagnosis but before the effects of the disease) and tertiary prevention (prevention after the sequelae caused by the disease)^[33];
Studies quantifying the potential impact of smoking prevalence on cancer incidence have shown that hundreds of thousands of cancer cases could be prevented by reducing tobacco consumption.^[34].

Health inequalities:

Significant disparities remain in exposure to risk factors according to sex, socioeconomic status and age:

Children and adolescents are more vulnerable to the health effects and risks of smoking and second-hand smoke^[35];
Socially disadvantaged populations and low-income households have higher rates of tobacco use and are more vulnerable to risk factors and cancer, and they also experience difficulties in accessing necessary treatment and health services.^[36] According to EU data, more than four in ten (43%) of those who said they had difficulty paying their bills “most often” were smokers, compared to just over a fifth (22%) of those who said they “never” had difficulty paying their bills.^[37];
In 2018, gender disparities were also of concern, as the prevalence of smoking among women was increasing.^[38] This is also very important because of the harmful effects of smoking and second-hand smoke on pregnant women.^[39];
LGBT community members have higher smoking prevalence than their heterosexual peers, remain particularly exposed to advertising, smoking and cancer^[40].

The economic cost:

Up to one fifth of healthcare expenditure in EU countries is considered a burden on society and healthcare systems. In the EU, tobacco consumption causes many losses, amounting to 9.9 million years of life lost prematurely, €7.3 billion in lost productivity and €25.3 billion in healthcare expenditure^[41];
The prevalence of cancer rates also places significant pressure on healthcare professionals^[42];
Preventing what is preventable through effective measures, including tobacco control,^[43] would also generate savings in health care (in human resources and funds) which, in turn, could be devoted to other health-related aspects requiring financing, leading to overall improvements and increased resilience of health systems.

Comprehensive policies for tobacco control

Policies such as excise taxes, indoor air quality laws, tobacco sales restrictions, advertising bans, plain packaging, and awareness campaigns help reduce smoking rates and tobacco use.^[44]

Tobacco taxation policies have proven to be the most effective and direct means of reducing smoking prevalence and cancer deaths.However, they are among the least implemented anti-smoking measures.^[45] For example, the World Health Organization's target of achieving a 30% reduction in current smoking prevalence by 2025^[46] will not be achieved by the European Union, since most EU countries are likely to miss it.^[47] More precisely, a EU tax policy can help achieve this goal through an increase in excise duties, which is estimated to result in a reduction of 18.5 million smokers and an increase of around 65 % in tobacco tax revenues.^[48]

These policies are enshrined in the World Health Organization's Framework Convention on Tobacco Control (FCTC),^[49] to which the EU and its Member States are Parties, and consist of comprehensive tobacco control plans across all governments, including:

Effective tobacco taxation measures to reduce the accessibility and attractiveness of tobacco products;
Ban on sales to minors ;
Measures aimed at protect non-smokers from exposure to tobacco smoke;
The affixing ofhealth warnings graphics on tobacco product packaging;
Of the advertising bans, of promotion and sponsorship tobacco products;
Raise awareness and provide access to information on the risks of smoking, ensuring that these are appropriate for the target audience (e.g. adolescents and young adults)
Ensure access to effective smoking cessation services ;
Of the effective measures to combat illicit trade including tracking and tracing systems at national, regional or international level;
Monitor tobacco consumption, trends and policy evaluation, and exchange information with other Parties.

Smoke Free Partnership policy recommendations for the European Beating Cancer Plan

The prevention pillar of the European Beating Cancer Plan must be recognised as an important stepping stone to improve the status quo on cancer in the EU and help achieve SDG 3 and the global targets for non-communicable diseases. In light of the crucial role of tobacco control in preventing cancer and non-communicable diseases and achieving the SDG targets, the Beating Cancer Plan must ensure that:

The implementation of the FCTC should be strengthened at EU level but also at national level through all available policy instruments. In particular, FCTC obligations should be taken into account in policy design through a whole-of-government approach;
EU tobacco control policy recognised for its contribution to improving citizens' health. The directives currently under evaluation and revision, namely the European Tobacco Products Directive (2011/64/EU) and the European Tobacco Products Directive (2014/40/EU), play a crucial role in improving European public health in general and, in particular, in cancer prevention;
Ongoing evaluation processes include a review of the European Tobacco Advertising Directive (2003/33/EU) with the aim of strengthening the existing framework and reducing the ability of the tobacco industry to market and promote its products to children and young people;
A global objective aimed at reducing inequalities in health among vulnerable groups within countries and across the EU be pursued by 'raising the threshold' in terms of human health protection through effective tobacco control measures at EU level;
The Plan to Beat Cancer must also apply the principle of health in all policies (Health in all Policies) at EU level and must include the implementation of health impact assessments from the outset of policy design.

Importance of public health research in tobacco control

Article 20 of the Framework Convention on Tobacco Control requires Parties to develop and promote national research programmes, as well as health surveillance programmes at national, regional and global levels, and to exchange information related to tobacco control.^[50] Article 22 calls on Parties to cooperate in the implementation of the FCTC and in the exchange of information, expertise and research with the aim of strengthening tobacco control policies,^[51] and therefore to coordinate strategies and knowledge to lead to an optimization of tobacco control and cancer prevention.

Horizon Europe is the European Union's post-2021 framework programme for research and innovation. It includes an objective to focus on cancer research and prevention research through the Cancer Mission which is one of five broad societal mission areas identified within this framework.^[52] ^[53] Research into tobacco control should be part of the Cancer Mission's work under the programme Horizon Europe.

The Smoke Free Partnership (SFP) has identified a need for investment in independent policy research as an integral part of tobacco control with benefits for^[54] :

To assess links and provide evidence-based information on the effects of tobacco use on the incidence of cancer and other NCDs;
Help develop and determine effective policies to combat tobacco consumption;
Assess the effects of policies and measures on the prevalence of tobacco and tobacco-related diseases and provide data on the impact of tobacco control on public health and the economy;
Identify policy gaps and inform policy design, implementation and review.

In light of ongoing work on the programme Horizon Europe and the objectives of its Cancer mission, it is imperative to recognise the importance of research for tobacco control and its role in reducing the number of preventable deaths caused by NCDs. This also includes policy-oriented research on practices at population level. Currently, tobacco control research does not integrate policy interventions. Furthermore, it is also unevenly distributed across the EU. To improve the status quo, it would be necessary to:

European Union policy makers recognise the role of tobacco control in cancer and NCD prevention under the programme Horizon Europe and its Cancer mission;
European Union policy makers support the establishment of a European research infrastructure for multidisciplinary cross-border collaboration, aimed at helping to fill research gaps in tobacco control policy.

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Health at a Glance: Europe 2018: State of Health in the EU Cycle, OECD Publishing, Paris. https://doi.org/10.1787/health_glance_eur-2018-en [7] Lung Cancer-Small Cell: Risk Factors and Prevention. 2019. Cancer.net. https://www.cancer.net/cancer-types/lung-cancer-small-cell/risk-factors-and-prevention [8] Global, regional, and national comparative risk assessment of 79 behavioral, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet. 2016, October 08. pp. 1659-1724. [9] Factsheet on Tobacco Taxation. 2018. Prevent20. Tax Tobacco, Reduce Cancer. https://wecanprevent20.org/wp-content/uploads/2018/06/Prevent20_onepager_FINAL.pdf [10] European Tobacco Use Trends Report 2019. 2019. Ibid [11] European Tobacco Use Trends Report 2019. 2019. Ibid [12] There are 16 cancers that can be caused by smoking. Walsberger. S. 2016. Cancer Council. 31.05. https://www.cancercouncil.com.au/blog/there-are-16-cancers-that-can-be-caused-by-smoking [13] Bray, F., et al. 2018. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: A Cancer Journal For Clinicians, ACS Journals, 68, 394-424. https://acsjournals.onlinelibrary.wiley.com/doi/epdf/10.3322/caac.21492 [14] Tobacco and Oral Health Factsheet. 2018. World Health Organization Europe http://www.euro.who.int/__data/assets/pdf_file/0005/369653/Fact-Sheet-on-Tobacco-and-Oral-Health-2018-eng.pdf [15] OECD/EU. 2018. Ibid [16] OECD/EU. 2018. Ibid [17] OECD/EU. 2018. Ibid [18] “The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General.” 2014. Office of the Surgeon General. HHS. https://www.ncbi.nlm.nih.gov/books/NBK179276/pdf/Bookshelf_NBK179276.pdf [19] European Commission, 2017, Special Eurobarometer 458, Attitudes of Europeans towards tobacco and electronic cigarettes, p.4, https://core.ac.uk/download/pdf/83648277.pdf [20] World Health Organization (WHO), World Health Statistics data visualizations dashboard, Data tables – Region data, Agestandardized prevalence of current tobacco smoking among persons aged 15 and older, 2016, last updated 2018/03/23 https://apps.who.int/gho/data/view.sdg.3-a-data-reg?lang=en [21] European Commission, 2017, Special Eurobarometer 458, Attitudes of Europeans towards tobacco and electronic cigarettes, p.4, https://core.ac.uk/download/pdf/83648277.pdf [22] Ibid. p.20 [23] Ibid., p.79 [24] “Health effects of second-hand smoke”. 2019. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/infographics/secondhand-smoke/index.htm#smokefree [25] Argue. E. 2019. “Third-Hand smoke exposure and results”, Eurasian Journal of Pulmonology, Official Publication of the Turkish Respiratory Society, 21 (2), pp. 81-86. https://bit.ly/35Ne1Ih [26] OECD/EU. 2018. Ibid [27] Torre, Lindsey A., Siegel, Rebecca L., Ward, Elizabeth M., Jemal, Ahmedin. 2014. “International Variation in Lung Cancer Mortality Rates and Trends among Women.” Cancer Epidemiology, Biomakers & Prevention 23 (6): 1025-1036 https://cebp.aacrjournals.org/content/cebp/23/6/1025.full.pdf [28] Kisling LA, M Das J. Prevention Strategies. [Updated 2019 Jan 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537222/ [29] Wallace R.B. Primary prevention. In: Breslow L, Cengage G, editors. Encyclopedia of Public Health [online]. 2006. [cited 2010 Mar 30]. Available from URL: http://www.enotes.com/public-health-encyclopedia/primary-prevention [30] “Primary prevention of cancer through mitigation of environmental and occupational determinants”. 2011. World Health Organization: https://www.who.int/phe/news/events/international_conference/Background_interventions.pdf [31] “Lung Cancer”. Prevent Cancer Foundation. https://www.preventcancer.org/education/preventable-cancers/lung-cancer [32] “Lung Cancer, Symptoms”. Prevent Cancer Foundation. https://www.preventcancer.org/education/preventable-cancers/lung-cancer [33] Joseph Menzin, Lisa M Lines & Jeno Marton (2009) Estimating the short-term clinical and economic benefits of smoking cessation: do we have it right?, Expert Review of Pharmacoeconomics & Outcomes Research, 9:3, 257-264, DOI: 10.1586/erp.09.28 [34] Tackling the tobacco epidemic in the Nordic countries and lower cancer incidence by 1/5 in a 30-year period—The effect of envisaged scenarios changing smoking prevalence Andersson, Therese M.-L. et al., European Journal of Cancer, March 2018. DOI: https://doi.org/10.1016/j.ejca.2018.02.031 [35] European Tobacco Use Trends Report 2019. 2019. World Health Organization Regional Office for Europe http://www.euro.who.int/__data/assets/pdf_file/0009/402777/Tobacco-Trends-Report-ENG-WEB.pdf?ua=1 [36] European Tobacco Use Trends Report 2019. 2019. Ibid [37] European Commission, 2017, Special Eurobarometer 458, Attitudes of Europeans towards tobacco and electronic cigarettes, p.9, https://core.ac.uk/download/pdf/83648277.pdf [38] European Tobacco use Trends Report 2019. 2019. Ibid [39] Unfair Tobacco, Women need tobacco control, https://unfairtobacco.org/en/women-need-tobacco-control/ [40] Tan. SLA 2019. “Inequities in tobacco advertising exposure among young adult sexual, racial and ethnic minorities: examining intersectionality of sexual orientation with race and ethnicity.” Tobacco Control, BMJ Journals. https://tobaccocontrol.bmj.com/content/early/2019/12/09/tobaccocontrol-2019-055313 [41] European Commission, A study on liability and the health costs of smoking, DG SANCO (2008/C6/046), December 2009, https://ec.europa.eu/health/sites/health/files/tobacco/docs/tobacco_liability_en.pdf [42] OECD/EU. 2018. Health at a Glance: Europe 2018: State of Health in the EU Cycle, OECD Publishing, Paris. https://doi.org/10.1787/health_glance_eur-2018-en [43] OECD. 2018. Ibid [44] OECD/EU. 2018. p.112 [45] 2018 Global Progress Report on Implementation of the WHO Framework Convention on Tobacco Control. 2018. WHO Framework Convention on Tobacco Control: https://www.who.int/fctc/reporting/WHO-FCTC-2018_global_progress_report.pdf [46] “WHO Global Report On Trends In Prevalence Of Tobacco Smoking 2000-2025 – Third Edition”. 2019. World Health Organization. https://www.who.int/publications-detail/who-global-report-on-trends-in-prevalence-of-tobacco-use-2000-2025-third-edition [47] “WHO Global Report On Trends In Prevalence Of Tobacco Smoking 2000-2025 – Third Edition”. 2019. Ibid. [48] The calculations are developed through a dynamic model by the Economic and Health Policy Research team at the American Cancer Society with a global coalition of cancer groups, called Prevent20. Please note that the calculations are based on the first edition of the World Health Organization Global Report on Trends in Tobacco Smoking 2000-2025. For more information, please refer to the Smoke Free Partnership Tobacco Tax for a Healthier Europe (SFP Position Paper on the Revision of the Tobacco Tax Directive (TTD), available here. [49] World Health Organization Framework Convention on Tobacco Control (FCTC), https://www.who.int/fctc/text_download/en/ [50] “Article 20: Research, surveillance and exchange of information”. 2018. WHO Framework Convention on Tobacco Control. https://apps.who.int/iris/bitstream/handle/10665/42811/9241591013.pdf?sequence=1 [51] “Article 22: Cooperation in the scientific, technical and legal fields and provision of related expertise”. 2018. WHO Framework Convention on Tobacco Control. https://apps.who.int/iris/bitstream/handle/10665/42811/9241591013.pdf?sequence=1 [52] Mission area: Cancer. Horizon Europe – the next research and innovation framework program (2021-2027). 2019. European Commission https://bit.ly/2szJfnq [53] Mission area: cancer. 2019. European Commission. https://ec.europa.eu/info/horizon-europe-next-research-and-innovation-framework-programme/mission-area-cancer_en [54] “Position Paper on Tobacco Control Research”. 2018. Smoke Free Partnership. https://smokefreepartnership.eu/news/sfp-position-paper-tobacco-control-research