Smoking- or nicotine-free generation, or both? What should be the public health priority?

On the tobacco control front, the situation has been gradually improving in the last decades in Europe, including the countries of its eastern half. In Poland, the sale of cigarettes has been showing a steady decline since the 1990s, from 100 billion cigarettes a year in 1990 to 40 billion in 2014 [1]. In several countries of Western Europe, the improvement has been even more marked. An example of this trend is Great Britain, where the smoking prevalence among adults (16 years and older) in 2015 has fallen to 16.9%, the lowest level recorded since 1974 when national surveys on smoking in Great Britain first began [2].
However, during the last decade, the largest changes in smoking rates in Europe and the United States were observed among children [3, 4]. Smoking among children is a particularly important indicator because the clear majority of smokers pick up the habit in their adolescence or during their teenage years. Initiation of smoking after the age of 25 is rare [5]. Due to this fact, every evidence-based tobacco control programme, with the goal of achieving long-term results, should emphasize the prevention of smoking initiation among children and youth [6].
One of the best measures of smoking among adolescents is the rate of daily smoking. In Poland, in the years 2004-2014, the proportion of daily smokers in all age groups decreased by half. In 2014, the proportion of daily smokers among 15-year-old children was around 10% in both genders. In the group of 13-year-old youth, it was 4.2% in boys and 5.3% in girls. Finally, in the group of 11-year-old children, it was around 1.5% in both genders (Fig. 1) [7, 8].
During the last years, some signs of a slowdown of the smoking prevalence decline among girls in Poland have been observed (11-, 13-, and 15-year-olds). Among boys, this slowdown seems not to have taken place (Fig. 1). There have been suggestions that this could be an effect of the appearance on the Polish market of e-cigarette products, their aggressive marketing, and their growing popularity among children [9-12]. However, it is still too early to conclude whether this is the case.
However, the real revolution in smoking among children in the last decade took place in Norway. In 2001, Dagfinn Høybråten, then the Health Minister of Norway, announced that his goal was to reduce smoking among children in grades 8-10 (age 13-15) by half. A few years later, this goal was reached. Now, fifteen years later, studies show that the decline has continued. The proportion of daily smokers among children aged 15 in Norway in 2014 was down to 2.1% among boys and 0.6% among girls [3]. This example of the success in the fight against smoking among children in Norway is another piece of evidence indicating that a complete eradication of smoking is within a reach.
In 2014, daily use of snus among 15-year-old was reported by 9.5% of the boys and 3.9% of the girls, slightly (insignificantly) lower than in 2010 [13]. During 2002-2010, among 16-17-year old’s, smoking of cigarettes decreased, and use of snus increased [14]. To what extent use of snus has replaced use of cigarettes and thereby contributed to the decline of smoking prevalence among adolescents in Norway needs further study.
The struggle against the use of traditional cigarettes must remain the focus of public health efforts in the years to come. The belief that e-cigarettes are the silver bullet that will lead to the eradication of tobacco-related diseases may turn out to be an illusion not sufficiently supported by scientific evidence. Some studies suggest that their effect might be the opposite, as the development of the e-cigarette market could disrupt the steady progress that tobacco control has made towards a smoke-free generation [15]. Some research has indicated that use of e-cigarettes among youth may increase the risk of starting using conventional cigarettes [16]. The increasing popularity of a device that vaporises pure nicotine should not be treated as a replacement for concerted efforts towards building health competence in any society. While e-cigarettes, if proven to be more or less harmless, could have their place as one of the many forms of tobacco cessation aids, and they should be subject to all the legal rigors and regulations that are required of this type of drugs. This belief is reflected in the new legislation passed in July 2016 by the Polish government [17], which, among others prohibits the sale of e-cigarettes to children under 18 years of age, the advertising of e-cigarettes, as well as the use of e-cigarettes in public places (just as is the case with traditional cigarettes).
In Norway, production, import, and sales of e-cigarettes and e-juice containing nicotine have been prohibited but some private import and use of e-cigarettes is taken place. With the connection to the recent EU Tobacco Products Directive [18], the Norwegian tobacco legislation has been revised, and the legislation has been expanded to cover e-cigarettes as well. Import and sales of e-cigarettes containing nicotine will be legal from 2017. This is to make e-cigarettes easily available for established smokers who would like to stop smoking, and to increase product control. The tobacco legislation has been adjusted to include regulations on e-cigarettes. Some regulation of product and sales, largely consistent with regulations related to tobacco products, as well as the EU Tobacco Products Directive are in place. Regulations include:
• registration at least six months in advance with The Norwegian Medicines Agency of all kinds of e-cigarettes to be sold on the Norwegian market,
• health warnings on packets,
• prohibition of self-service in places where the product is sold,
• ban on use of e-cigarettes in public places,
• ban on advertising (with minor exceptions related to internet-based display of products),
• prohibition of sales to customers under 18 years of age.
Separate regulations will be issued on exceptions from the ban on prohibition of product display in establishments where e-cigarettes are sold.
In summary, the rates of smoking have been steadily decreasing in the last decades, not only in Norway or the USA, but also in less wealthy countries such as Poland. The question of tobacco control today is whether smoking of traditional cigarettes will be replaced using pure nicotine administered by various types of nicotine delivery devices, such as e-cigarettes, or the more recent Next Generation Nicotine Delivery products, which are becoming available on global markets [19]. In the report of the US Surgeon General published in December 2016, it was indicated that in the USA, in 2014 more children used nicotine delivery devices (so-called electronic cigarettes) than smoked conventional cigarettes. In the report from the U.S. Surgeon General, several harmful effects of use of e-cigarettes are mentioned. The full impact of e-cigarette use on health is not yet known [20, 21]. An additional concern is whether the first contact with addictive substances for children will be increasing in the form of marijuana and other psychoactive substances, which are being legalised in growing number of countries and regions. We do not yet know what the scale of this occurrence will be, but it is important for the tobacco control community to continue to monitor these developments closely, before they are faced with a new serious public health problem and a growing risk to physical and mental health of children.

Disclosure

Authors report no conflict of interest.

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Authors’ Contributions

WAZ prepared concept and design of the publication. WAZ and LEA collected data and analysed them, critically revised and finally approved the article. WAZ, LEA, OS and JM participated in writing the article.