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Global health economics and policy experts highlight the public benefits of replacing cigarettes with better alternatives




Encouraging smokers to switch from cigarettes to alternative products such as e-cigarettes and heated tobacco isn’t just good for the individuals’ health but saves countries’ health systems massive amounts of money. The benefits flow from drawing on real world experience, getting the messaging right and pitching the tax incentives correctly, according to some of the world’s leading experts, writes Political Editor Nick Powell.

The Brunel First Annual Health Economics and Policy Forum was held in London, jointly organised by Brunel University Business School and the Nuffield Department of Primary Care Health Services at Oxford University. In his opening remarks, Professor Francesco Moscone, Brunel’s leader in healthcare management and wellbeing area of excellence, gave the findings of his research in both the United Kingdom and Italy.

If half of all cigarette smokers switched to e-cigarettes and heated tobacco, the National Health Service in England would save £500 million a year in direct costs, the equivalent figure in Italy would be €600 million. “You can cut hospital admissions, treatment costs and the suffering of patients and their families”, Prof Moscone said.


Improving healthcare is “not just a matter of increasing the number of doctors and nurses”, he added, “it’s also about the demand side”. There would be further indirect savings to the public purse as well, as there would be fewer seriously ill patients unable to work.

Setting impossible goals and bans alienates smokers and does nothing to improve health services’s sustainability, whereas pragmatic and moderate approaches will. Further savings, as well as public health benefits, could be achieved by cutting alcohol consumption and increasing physical activity, perhaps bringing the total direct saving in Italy to €1 billion. But Prof Moscone warned “I don’t believe in banning anything”.

In a presentation led by Professor Ae Sun Shin, Professor in Preventive Medicine at Seoul National University, the downsides of bans and a coercive approach were explored. She has studied the potential impacts of reducing risky behaviours on the incidence of non-communicable diseases in South Korea.

If all smoking and heavy drinking could be stopped overnight, there would be 116,600 fewer patients to treat that year. But “we observe what is happening in reality”.  The World Health Organisation has “very strict, severe goals, where they want to ban harmful products”.

If such an approach worked, it would have “a massive impact but people won’t follow directions in that way”.  A more moderate approach -one that actually worked- is to encourage people to switch to less harmful alternatives, such as low-alcohol beverages and alternative tobacco products like e-cigarettes and heated tobacco. That would leave the South Korean health system with 73,400 fewer cases to treat in a year.

It’s important to remember that the higher figure is for a theoretical ban that completely works. In practice, hospitals would have to deal with the consequences of people consuming illicit alcohol and cigarettes, which often include additional harmful ingredients and also evade taxation.

The wider public benefits of a realistic approach are also striking. Over 60% of these preventable cases would have been among South Koreans aged 20-64 - the working-age population driving the nation's economic engine. With the country facing a declining workforce due to low birth rates and restrictive immigration policies, safeguarding this demographic's health is of paramount importance.

Prof Shin’s analysis highlights the economic imperative underpinning public health policies. With an aging society and a projected workforce decline of 350,000 from 2021 to 2022 alone, mitigating preventable diseases through harm reduction could help bridge over 20% of this gap.

One important challenge for all countries is to get the tax policy right, so that people are incentivised to make sensible choices and not given perverse incentives to turn to criminals, such as those who smuggle or counterfeit cigarettes. Prof Catia Nicodemo, Professor in Health Economics at Oxford University, described the tipping point for so-called sin taxes as when a reasonable policy becomes “paternalistic overreach”. If those who set such taxes don’t want to face “hell”, as she put it, they must endure “the purgatory of risk”, in other words devise a system of risk-proportionate taxation.

Dr Zafira Kastrinaki, spoke from her experience as a member of the Council of Economics Experts at Ministry of Economy and Finance in Greece, which already applies differential taxation in favour of non-combustible tobacco products, compared with combustible ones. “We have to agree on what are the safer alternatives to cigarettes”, she said. The trick was to find “a good balance of taxation to counter the negative effects”.

The day’s discussion was notable for its open, interdisciplinary approach to the major challenges facing public health and tackling of non-communicable disease. There was none of the herd mentality that sometimes characterises academic discussions about cigarettes and the safer alternatives.

Rather, there was a real focus on establishing what actually works and what is achievable. Perhaps holding the forum in a business school brought some of the results-driven approach more often associated with free market enterprises, which have done so much to develop alternative products which offer dramatically improved public health outcomes.

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