History of smoking, tobacco control and smokers’ care in France| Tabaccologia

Abstract

After the discovery of tobacco, its use has spread worldwide. The symbolic function conveyed by the smoke from its combustion, and the physiological effects produced by its alkaloids, have interwoven smoking into the cultural systems of societies. The industrialization of cigarette production and its promotion began before the harmfulness of smoking were clearly demonstrated. Smoking is the leading preventable cause of death; 70% of tobacco is consumed in emerging countries, giving rise to fears of an increase in tobacco-related morbidity and mortality, and justifying tobacco control. This article describes the history of smoking, tobacco control and care to smokers in France.

Introduction

The discovery of America and tobacco by Christopher Columbus marked the beginning of the modern era. Smoking is associated with disease, death and high socio-economic costs. It has become a major global public health issue and international health authorities have established tobacco control. This article describes the history of smoking, tobacco control and smokers’care in France; it leads us to question the modalities that would make it possible to optimize this fight.

History of tobacco smoking

Discovery and expansion of tobacco use

Tobacco use spread to Europe after Christopher Columbus discovered the Americas in 1492. His companions, noted that inhaling smoke from cigars made from dried tobacco leaves seemed to give pleasure to the consumers [1-3].

The ceremonial function of smoke has existed since ancient times around the Mediterranean, on the American continent and in the East. As it rises from the earth to the sky, smoke is said to convey the relationship between men and gods. Today incense is burnt in churches. Symbolic function of smoke and physiological effects induced by tobacco would have enabled smoking to become embedded in the cultural systems of societies [1-3].

In 1560, Jehan Nicot de Villemain, French ambassador to Portugal, introduced tobacco to the French court to relieve the migraines suffered by Queen Catherine de Médicis ; he gave his name to tobacco’s main alkaloid: nicotine. In 1557, André Thevet cultivated a tobacco plant near the town of Angoulême, known as “herbe angoumoisine”. Tobacco use spread to Europe and the Ottoman Empire, navigators brought it to Japan and China [1,2].

Tobacco controversies

In 1572, Jean Gohory described the various tobacco plants. In 1660, Jean Royer de la Prade emphasized its therapeutic virtues. In the 17th century, it was proposed to revive drowning victims, but at the same time, Fagon, physician to King Louis XIV of France, believed that it shortened life. In the 19th century, many writers (Rimbaud, Baudelaire, George Sand) were smokers but Victor Hugo and Balzac were against tobacco, recognizing it as a hallucinogenic superior to alcohol. The neurologist Charcot observed that the moderate use of tobacco and alcohol softened morals; the mutual conditioning of smoking and alcoholism seems to have been perceived at this time [1,2]. After the isolation of nicotine by Vauquelin in 1809, the toxicity of the alkaloid was recognized [1,2]. In 1821 the “Dictionnaire des sciences médicales” suggested limiting its use. At the end of the century, Doctor Jolly regarded tobacco as one of the scourges with tuberculosis, syphilis and alcoholisme of his time. In 1892, the French Academy of Medicine considered it a “poison” [2]. However, since Necker, minister of the French King Louis XVI, tobacco taxes became a fine fiscal invention.

Tobacco control

A) From the discovery of tobacco to the Second World War

Initially, tobacco was consumed in the form of quids, then its use diversified, giving rise in the 18th century [1-3]. The first anti-smoking measures in Europe were authoritarian and repressive [1-4]. In France, the fight did not take shape until 1868, when Emile Decroix, a veterinary surgeon in the French army, noticed that “French cavalrymen who smoked were less active than non-smokers” and founded the “Association française contre le tabac”, which issued the first warnings against tobacco [3]. In the early 20th century, and especially after World War I, tobacco consumption in the form of cigarettes increased with the industrialization of its manufacture [2,3]. As early as the 1930s, the German epidemiologist Mueller [4] had identified a link between lung cancer and smoking, but anti-smoking campaigns were unsuccessful in Hitler’s Germany [5].

B) After the Second World War

Following the discovery of the link between smoking and lung cancer [6,7], the addictive nature of smoking and its involvement in numerous diseases [8]. In 2003, the Framework Convention on Tobacco Control (FCTC) [9] was ddopted by more than 170 countries.

1) Tobacco control legislation

The first tobacco control law was proposed by health minister Simone Veil (July 9, 1976) [10]. It mainly attacks tobacco advertising, provides for smoking bans in places for collective use and requires the words “Dangerous abuse” to be written on cigarette packets. A law submitted by health minister Claude Evin (January 10, 1991) [11], relating to tobacco use and alcoholism promotes the increase of tobacco prices, smoking ban in premises for collective use. The last ban on smoking in public places (February 1, 2007) prohibited smoking in all closed and uncovered places open to the public (e.g. public transport and railway stations).

2) Implementation of tobacco control

In France smoking is the leading cause of avoidable (75,000 deaths per year) and early (before age 65) mortality, from cancers (45,000 deaths per year) and cardiovascular disease (17,000 deaths per year) [12]. A mobilization plan against addictions was drawn up for the period 2018-2023 [13] with 6 objectives : protecting individuals from the earliest age (1); responding better to the consequences of addictions for people (2); enhancing knowledge about addictions and promoting public information (3); guaranteeing the effectiveness of public action across the teritory (4); improving the fight against traffic (5) and strengthening international cooperation (6).

Successive programs [13-15] have been implemented to build a tobacco-free society, focusing on 5 areas: protecting young people from smoking by increasing the price of tobacco, tightening controls on the sale of tobacco and vaping products, and introducing plain packaging for all tobacco and vaping products (1); promoting smoking cessation with access to nicotine replacement therapy (NRT) reimbursed by the French health insurance system (2) and through the “Tabac Info Service” quitline (2); safeguarding the environment from tobacco pollution by extending smoking and vaping bans to outdoor spaces and banning the sale of disposable vaping products (3); transforming the tobacco industry and stepping up the fight against tobacco trafficking by harmonizing tax policies and prices across the European Union (4); Improving knowledge of the dangers of tobacco and vaping products (5).

Guideline for smoking cessation

Expert meetings have defined recommendations for the management of smoking cessation [16-19] and concluded that behavioral and cognitive therapies (CBT) and pharmacological treatments (NRT, varenicline, bupropion) are effective in smoking cessation, especially the combination of CBT and pharmacotherapy. Smoking cessation strategies have been developed for pregnant women (2004,2020) [20,21], the perioperative period (2005) [22], patients with psychiatric disorders (2009) [23] and cancer patients [24]. Opinions have been issued on pharmacist intervention in smoking cessation [25] and on the toxicity and benefits of electronic cigarettes (e-cigs) [26,27].

Currently, health professionals are trained in smoking cessation as part of their university training and through 5 academic diplomas in tabacology and smoking cessation. The Société Francophone de Tabacologie (SFT) [28] brings together professionals working in the field of tabacology (prevention, care, research) with the aim of stimulating scientific research on smoking and its health consequences (1), on tobacco dependence and related behaviors (2), facilitating the dissemination and application of this research (3), and promoting education on tobacco dependence (4).

Current status of tobacco control

A) Organization

In the current context, an addiction prevention network [29] has been set up with the aim of increasing the awareness of health care institutions with regard to the prevention of addictive behaviour. Within health facilities, addiction units and mobile smoking cessation teams provide care for smokers [30]. A national observatory [31] collects and analyses data on drug addiction. In each French region, tobacco control associations train health professionals in smoking cessation interventions and facilitate the exchange of knowledge between them. In addition, twenty-three non-governmental associations (Alliance contre le tabac) have joined forces to present their views to the health authorities [32].

B) Trends in tobacco control

1) Reduction in tobacco consumption

From 1991 to 2023, tobacco control measures have reduced the prevalence of tobacco smoking. In 1991, 37% of adults aged 18 to 75 smoked (38% of men, 20% of women and 25% of boys and girls aged 17) [33]. In 2023, 31% of adults smoked (25.4% daily : 27.1% of men, 21.7% of women and 15.6% of boys and girls aged 17 years). The prevalence of daily smoking remains significantly higher among those with low education or income (lowest: 30.8% vs. highest: 17.3%) and among the unemployed (42.3%); e-cig use increased in 2023 compared with 2016 (adult daily users: 5.5% vs. 2.5% and 6.2% at age 17) [34,35].

2) Improving tobacco control and smoker care

Additional measures are proposed to improve the effectiveness of tobacco control : a faster and higher rate of increase in tobacco prices (1); smoking cessation counseling by pharmacists with TNS reimbursement should encourage smoking cessation (2); a ban on disposable vaping devices and non-tobacco flavors in e-cigarette liquids, as well as a ban on heated tobacco products and nicotine pouches (3). All health care providers are mobilized in the latest Tobacco Control Program (PNLT 2023-2027) [15] to build the first tobacco-free generation in 2032 (less than 5% smokers).

Advances are expected from a pilot program for lung cancer screening (2025) using annual low-dose computed tomography (CT) scans in the population of smokers and former smokers, combined with a smoking cessation intervention for smokers [36]. Further progress is expected from the strengthening of smoking cessation in territorial professional health teams (CPTS), which bring together professionals from the same region.

C) What about harm reduction?

Quitting smoking has been shown to reduce smoking-related mortality, not simply reducing consumption [37-38]. The tobacco industry offers products (e.g. snus, nicotine pouches, heat-not-burn tobacco products) as an alternative to cigarettes [39]. They are not free of toxicity and perpetuate nicotine dependency [40-43]. In 2016, a group of French experts proposed practical guidelines for the use of e-cigarettes as a second-line smoking cessation strategy [26]. French health authorities imposed a ban on snus and nicotine pouches. While exclusive use of e-cig appears to reduce short-term risks, the long-term safety is not fully understood [27]. Recent studies suggest that exclusive e-cig use may help people to quit smoking [44,45]; however, the use of disposable or nicotine-enriched devices (JUULs) by young people could lead to nicotine dependence and subsequent cigarette consumption [27]. In response, France and other countries, at the initiative of the WHO [46,47], are implementing measures to discourage the use of e-cigarettes by young people.

Conclusion

Tobacco addiction is a chronic disease marked by a fatal outcome one time out of two. It could be responsible for a billion deaths in the 21^st century. The diversification of tobacco products rise to new public health issues. Tobacco control requires global intervention including regulations, pricing policies, public information, improved care for smokers, mobilization of health care professionals. Despite the advances, efforts are more necessary than ever: “This is not the end. This isn’t even the beginning of the end but may be this is the end of the beginning” Wiston Churchill.

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