Adjunct Professor and Medical Doctor Michele Cecchini leads the work on public health at the OECD – the Organisation for Economic Co-operation and Development, helping countries implement better public health policies for better lives.
Based on your work with the Organisation for Economic Co-operation and Development (OECD), how do economic evaluations influence the development and implementation of tobacco control policies targeting young people, especially regarding electronic cigarettes (e-cigarettes)?
Michele Cecchini: As you know, the OECD is an intergovernmental organisation that focuses specifically on economic aspects. We believe that economic evaluation is a fundamental component of any assessment, whether it concerns tobacco or other public health issues.
The OECD is a global leader in conducting economic evaluations of policies. By this, we mean a broader perspective that encompasses more than just a simple cost-benefit analysis. In Europe in particular, it is widely recognised that we need to take a more holistic view with the broader concept of the economics of well-being.
At the OECD, we define the evaluation of a policy, such as tobacco policy, across six dimensions, developed in collaboration with EU Member States and OECD member countries. Firstly, the economic evaluation should consider the policy’s impact in terms of effectiveness, as it should improve population health. Secondly, it must be cost-effective, delivering a good return on investment.
Thirdly, the policy should be affordable; some policies may be effective and cost-effective but could be impractical to implement on a larger scale. Fourthly, it needs to consider equity, particularly regarding marginalised groups such as minorities and individuals with lower socio-economic status. The fifth dimension is that the policy should be politically feasible. And finally, it should be scalable and transferable, meaning that best practice from one Member State can be adapted and applied in others.
Most e-cigarette policies can benefit from the lessons learned from decades of tobacco policy implementation. We know that when tobacco policies are implemented effectively, at appropriate levels and with the right design, they can reduce smoking rates and assist individuals in quitting smoking.
In your research on France’s tobacco control policy, you emphasised the substantial health and economic advantages of this intervention. How can these findings guide policies to tackle the increasing use of e-cigarettes among young people throughout Europe?
Michele Cecchini: I believe there are three main lessons from our work on France’s tobacco control policies that are also applicable to e-cigarettes, particularly regarding the younger generation.
- The first lesson is the need to implement a comprehensive package of interventions. No single policy on its own can address all the factors driving tobacco or e-cigarette use. Therefore, our approach must be holistic.
- The second lesson is that policies should not be implemented as one-off measures but should rather be continuously strengthened over time. Taxation is the most cost-effective measure in this field. It’s crucial to maintain this intervention’s effectiveness consistently over the years.
- The third lesson regards the importance of reducing initiation of smoking and e-cigarette use as much as possible. Preventing initiation tends to be more cost-effective and manageable. While we should certainly support existing users in quitting, focusing on reducing initiation is key from an economic evaluation standpoint, especially for young people.
We calculated that France’s policy package significantly achieved its intended results, even during the initial phases of the COVID-19 pandemic, which was included in our evaluation period. Even taking into account the impact that lockdown had on people’s lifestyles, the policy had a significant impact. This set of interventions was undoubtedly a worthwhile investment for France and something that other countries can also regard as best practice.
Drawing on lessons from the OECD report about tobacco taxation reforms in Latin America and the Caribbean, how can similar strategies be adapted and applied in European countries to effectively reduce tobacco and e-cigarette use among young people?
Michele Cecchini: We plan to extend this analysis to central and eastern European countries, which will provide a specific analysis for that subregion within Europe.
There are two main messages from the report on tobacco taxation in Latin America and the Caribbean.
The first key message is that there is a widely agreed-upon set of policies known as the MPOWER package, which is accepted almost universally, certainly by EU Member States. This framework can also serve as a strong basis for addressing the issue of e-cigarettes. However, it is important to recognise that we cannot simply copy and paste the tobacco policies for e-cigarettes; we need to adapt certain aspects of these policies to fit the unique characteristics and challenges of e-cigarettes.
Moving to the second point, raising taxes is probably the most effective single intervention in this area. While it should not be implemented in isolation, it is a vital component of the overall strategy. However, when it comes to e-cigarettes, we cannot simply apply the same taxation methods used for tobacco products. This is primarily due to the more diverse nature of e-cigarette products. For instance, we must consider whether to tax the devices, the liquid, the nicotine content in the liquid or the flavours.
Compared to traditional tobacco products, which are relatively homogenous, there are many more variables to address in the case of e-cigarettes. Therefore, while taxation is an important starting point, we need to conduct further work to adapt these strategies specifically for the e-cigarette market.
Reflecting on the outcomes of tobacco control policies, should public health strategies focus more on preventing initiation of e-cigarette use or on managing addiction among young people?
Michele Cecchini: It’s both an easy and a difficult question. It’s difficult because the question implies that someone is obliged to choose one or the other. As I mentioned earlier, I believe we need to address both aspects. For example, we can look at what France did regarding their tobacco control policy. As I noted at the beginning of our discussion, their approach was effective because it tackled both issues.
From an economic perspective, stopping the problem at its source is often more cost-effective than trying to manage the consequences. To address the issue of smoking, we first need to prevent people from taking up smoking; otherwise, we risk entering an endless cycle of managing the fallout. Stopping the initiation of smoking is certainly a top priority, but it should go hand in hand with providing support for those who want to quit smoking, including vaping devices.
That said, if we want to see a significant reduction in health expenditure in the short term, we must focus on helping people who want to quit smoking. These individuals are the ones who are likely to develop smoking-related diseases in the coming years.
Flavoured e-cigarettes are very popular among young people. What challenges do these flavours present to public health and how should policymakers respond?
Michele Cecchini: The issue of flavours in e-cigarettes is highly debated, particularly among EU Member States, which are discussing stronger policy actions regarding vaping. One significant concern is that many flavours, such as bubble-gum, are particularly appealing to the younger generation.
There are several challenges to consider on this matter. First, these flavours are very appealing and can encourage the initiation of smoking, acting as a gateway for many young people. Second, from a practical standpoint, we are still struggling with the legislation and enforcement necessary to ensure that the contents of these products are safe. We also need to understand the biological impacts better and gather more evidence on this aspect.
From an advertising perspective, there is certainly much work to be done. One option is to regulate the types of flavours available. Some countries have implemented bans on certain flavours, which can be effective if properly enforced. Additionally, there are regulations in place to prevent underage individuals from purchasing these products, but the issue lies in enforcing these laws. Many existing regulations are not enforced adequately, allowing younger people to gain access to e-cigarettes.
How crucial are educational campaigns and school-based programmes in preventing young people from starting to use e-cigarettes?
Michele Cecchini: Educational campaigns are important for increasing awareness and acceptance of public health initiatives. For instance, understanding the negative health impacts of relatively new products like e-cigarettes can have a real impact on people’s decisions on whether or not to use a certain product.
This knowledge shouldn’t be taken for granted. Even with well-established products like tobacco, many people were unaware of the health risks until major educational campaigns were launched. The same applies to alcohol. Therefore, similar efforts should be directed towards e-cigarettes.
Research indicates that a higher level of education and access to information leads to better decision-making, promoting healthier lifestyles. Additionally, informed individuals are more likely to support the implementation of stricter policies regarding these products. However, it’s important to note that education policies alone are not sufficient to address lifestyle-related health interventions. We can’t stop here because education alone doesn’t prevent people from maintaining bad habits. It didn’t work for tobacco. It didn’t work for other lifestyle interventions such as those related to unhealthy diets. In my opinion, it will not work for e-cigarettes.
Looking ahead, what are the key strategies for tobacco control in Europe, primarily to address e-cigarette use among young people?
Michele Cecchini: When it comes to e-cigarettes, I would say we need to focus on four key points. First, the flavour is crucial, especially if you want to target the younger generation; it’s a top priority. Second, we need to consider the age at which people can access these products. Many European countries have already implemented regulations and we could consider extending these age restrictions further.
The third point is advertisement regulation, particularly regarding social media, which is becoming increasingly important as young people spend a significant amount of time on these platforms. However, this area is currently quite unregulated due to social media’s transnational nature. Some countries are taking positive steps to address this issue, not only regarding e-cigarettes but also tobacco and alcohol products. For instance, around 10 years ago, Finland implemented a regulation targeting advertising of alcohol to young people on social networks.
A significant gap in that regulation was how to control posts by private individuals who promote harmful alcohol consumption. For instance, consider a 16-year-old with no financial links to the alcohol industry who promotes the consumption of specific alcoholic products. This shows the need for further action in this area, which should happen in collaboration with other states. Implementing a Europe-wide regulation on this kind of transnational issue, including advertisements concerning tobacco and e-cigarettes, is undoubtedly the right approach.
The final point is enforcement. We previously mentioned that it’s crucial to ensure that the existing regulations are strongly enforced. This, of course, requires funding, as enforcement comes with costs. However, examples from various countries and other sectors, such as tobacco control, demonstrate the benefits. As I mentioned, it’s not just a cost; it’s an investment that pays off.