The world has understood the risks of smoking for several decades and that quitting the habit is essential to maintaining one’s good health, but not everyone can break free from the habit. Traditional cigarettes contain over 6,000 chemicals and ultrafine particles, 93 of which are on the US Food and Drug Administration (FDA) list as potentially harmful. Most, roughly 80 of those listed, are or are potentially carcinogenic, with the end result remaining the same – smoking is the most important risk factor for cardiovascular disease and various forms of cancer.
And yet, despite the empirical data that reveals the risks of smoking, more than 60% of those who are diagnosed with cancer continue to smoke.
But an increasing effort from sectors of the scientific community has focused on harm reduction through alternative solutions – such as E-cigarettes and heated tobacco – with the overall goal aimed at minimizing the damage that people suffer from unhealthy lifestyle choices, while at the same time not limiting or impinging upon their rights to make personal choices.
The concept of harm reduction refers to programs and practices aimed at minimizing the health and social impacts that are associated with the use of harmful products, such as cigarettes. Scientific studies and medical practitioners have noted that E-cigarettes and heated tobacco, as modified risk products, can help smokers in the path of detachment from traditional cigarettes.
However, as the technology for heated tobacco and E-cigarettes has improved, a bitter chasm has appeared between those advocating for the use of less harmful products as a pragmatic and realistic approach and those who think prevention and cessation through anti-smoking campaigns and increased taxation are the only methods needed to halt the use of harmful products.
Dr. David Khayat, the former president of France’s National Cancer Institute and head of medical oncology at the Clinique Bizet in Paris, is one of the most respected and forceful voices who opposes what he says are ineffective peremptory slogans like ‘quit smoking or die’.
“As a doctor, I cannot accept ‘stop or die’ as the only choice offered to a patient who smokes,” Dr. Khayat has previously explained, while emphasizing that the scientific community should “play a stronger role in convincing policymakers around the world to reconsider and be more innovative in their tobacco control strategies, including coming to a realization that some levels of our bad behavior by people are inevitable, but that limits on their freedom and dire warnings about the consequences of their actions “is not a viable path” towards reducing health risks.
While attending the Global Forum on Nicotine in Warsaw, Poland, Dr. Kayat spoke with New Europe about these topics and his vision for the path ahead.
New Europe (NE): I wanted to begin this with somewhat of a personal angle to my question, my stepfather died of throat cancer in 1992. He was a heavy smoker; an army officer and a veteran of World War II. He’s been gone for quite some time, but the scientific research and medical information (about the health risks of smoking) were available to him for his review. He was originally diagnosed in 1990 but continued to smoke for some time, regardless of the diagnosis and the multiple treatments that he received for cancer.
Dr. David Khayat (DK): Let me tell you, there has been a recent big study that has shown that 64% of those who are given the diagnosis of cancer, smokers, for example, who are diagnosed with lung cancer, will continue to smoke until the end. So it’s not just people like your stepfather, it’s almost everybody. So why? Smoking is an addiction. It’s a disease. You cannot consider it just as some sort of pleasure or a habit or as a behavior. No, it’s an addiction; a disease.
This addiction, in the 2020s, is like the case of depression 20 years ago: “Please, stop being sad. Go out and have fun; see people and feel better.” No, it’s a disease. If you are depressed, you need to be treated for depression. And in this case (regarding nicotine), it’s an addiction and needs to be treated. It looks like the cheapest drug in the world, but it is an addiction.
Now, if we talk about the rise in the cost of tobacco cigarettes, when I became the advisor for (former French President) Jacques Chirac, I was the first one to raise the cost of cigarettes. In 2002, one of my missions was to fight against tobacco smoking. For the first time in France, in 2003, 2004 and 2005, I raised the cost of tobacco cigarettes from €3 to €4; €4 to €5, in less than two years. We had 1.8 million less smokers. The sets of cigarettes from Philip Morris went from 80 billion sticks per year, down to 55 billion. So, I did real work. But, what I found out two years later, those 1.8 million went back to smoking.
What has been shown recently, and what is interesting is after COVID, is that a pack of cigarettes costs more than €10 in France, one of the most expensive in Europe, is that this policy (of high pricing) didn’t work.
For me, what is totally unacceptable, is that these smokers are the poorest people in society; a guy who is unemployed and living off state social benefits. They continue to smoke. They’ll pay €10, and cut the money they would have used for the cost of their food. They’re eating even less. The poorest people in the country are already at the highest risk of obesity, diabetes, and cancer. The policy of higher prices for cigarettes has made the poorest people even poorer, and they continue to smoke and smoke even more.
The decrease in smoking that we’ve had in the last two years, at 1.4%, is only from those with disposable incomes or those who are wealthy. What this means is that the public policy, which I originally initiated, to control the prevalence of smoking by increasing the cost of cigarettes, has failed.
NE: What, exactly, was the initial concept that you had when you thought of the idea to raise the cost of cigarettes? To make them prohibitively expensive, which would make smokers turn away from them?
DK: Yeah, exactly. At that time, we had the experience of Australia, where they started to increase the price of cigarettes. The results, which we had requested, showed that after one year or a few months it looked like it was a very efficient way of doing things in terms of a public policy. But when looking at the long-term results, it simply doesn’t work. If you look at the NRT – the nicotine replacement therapy – which I made available to all French citizens, and which were totally reimbursed without a prescription, the efficacy was 60% after two months. After two years, however, it was less than 10%.
I did get 1.8 million fewer smokers, and I helped come up with a law to ban smoking in public places. I did my job to fight tobacco smoking, but after two years, it failed.
NE: Do you think that’s because, after a certain amount of time, the population adapts to the new reality?
DK: Exactly, that’s it. When I was interviewed earlier this year, I commented that French government, in their annual report earlier this year, mentioned that because of the rise in the cost of cigarettes to above €10, they had about 1% less smokers. Two weeks later, however, there was a report in the French media from the customs organization saying that the result of the huge increase in the price of cigarettes to more than €10, the illicit trade of cigarettes has reached a level that has never been seen before. So when the government says there are fewer smokers, that’s not backed by real data. The people buying counterfeit cigarettes on the street are not going to say, “Yes, I smoke fake cigarettes bought on the black market.”
The point is that the information the population is given, or fed with, is fake. The government, and this is (a) very political (motive), wants to say they’ve been very efficient and what we did was effective and good.
As a doctor, though, I don’t care about eradicating cigarettes. What I want is to eradicate smoking-related deaths. I am a doctor who, for 45 years, has seen my patients, like your stepfather, die from cancer. You can’t imagine how many of my patients I’ve lost in that time because they continued to smoke; maybe 30-40% of them. Can you imagine how many thousands I’ve seen die because we didn’t have a treatment in those days? Now we have immune-therapy and many other different ways to treat people. But what I’ve done, and what I want to do, has nothing to do with the economy of cigarettes. I am only concerned with the consequences of cigarette smoking. This is why I have committed myself to find any innovation that could help people have an alternative to quit smoking – of course, quitting is the best thing to do – or die. But the idea of “quit or die”, has been the basis of all of our policies – meaning that you understand that if you don’t quit, you will get a terrible disease that will eventually I want a third way.
From the perspective of a doctor and a scientist, the concept of a third way is the best method. Quitting is what you should do, but if you can’t, it’s my responsibility, as someone concerned about the public health situation, to find a way to help you have less consequences based on your bad behavior.
NE: So if my stepfather was here, and if you could give him some advice, how would you explain to him the “third-way” option in a way that would persuade him to be less skeptical?
DK: I would tell him that, first of all, I am not against him. In fact, I understand his position and his philosophy for his life. I would tell him that I understand that trying to quit an addiction to nicotine once you’ve been given the diagnosis of having potentially terminal cancer, which would mean having to undergo treatments like radiation, surgery, chemo… it’s an immense amount of stress. Try at that moment to tell someone to quit cigarettes. I had a (cancer) patient who was smoking from here (through the hole from a tracheotomy) It’s an addiction. It’s the same as trying to tell an obese teenager with a body mass index of 35 or 33 to stop eating pizza and nachos every day. You’re crazy. They’ll continue to sit in front of the TV and keep eating pizza and nachos.
I think, as a doctor, we have to consider all addictions as diseases. We have to understand the disease, the process of the disease, the mechanics of the disease, and find ways to treat the disease. The way is to try and share your logic, which is that I know if you continue your bad habits, you are going to die. But that is not enough. When you are an addicted person, you simply don’t fully understand that.
Now we come to a third way. If you look at the WHO data, in 1999, the first cause of death in the world was smoking. In 2017, almost 20 years later, the first cause of death was smoking. Meanwhile, every government in the world has been trying to do something against smoking. And yet, it’s still the first cause of death in the world. What’s the conclusion, based on those figures? It’s that all of those policies have failed.
Let’s look at the whole picture. Prohibition has been tried; threatening people who smoke was already tried; making smoking too expensive has been tried. Everything that was considered easy has been tried. Now there’s one thing that has to be understood, and this is where a lot of these people are a bit embarrassed, it’s that the so-called ‘third way’ for tobacco smokers is being led by the tobacco industry.
You know, when I was an oncologist and the advisor for Chirac, I would never, ever talk to them (tobacco industry companies).
NE: Is that because you and a lot of other policy-making officials and lawmakers automatically assumed that the tobacco industry would be disingenuous in their quest to find a third way?
DK: It’s because there were so many lies from them for a century. If look back to just 1982 in the US, not so much in Europe, there were advertisements saying that menthol cigarettes were safe. They had a long history of lying. There was an automatic feeling that we couldn’t trust them.
But, as a scientist, as well as a doctor, I want to see the data. I want to review the evidence. What happened was that I started to trust what I was reading when I saw the data from the FDA, which is not an easy institution to get through. The FDA has a huge research facility on tobacco in Florida. They tested E-cigarettes and heated tobacco against normal cigarettes and they stated that the first two could provide a better health alternative to the (smoking) population. Why? Because they are between 90-95% less toxic.
You have to understand that with cancer, whether you’re talking about the sun and skin cancer, red meat and colon cancer, almonds and breast cancer; whatever. It doesn’t matter. There’s always a carcinogen, an exposure to a carcinogen, and a dose response to the exposure and the risk. For example, eating one slice of ham every week, as opposed to 200 grams of processed meat every day, the risk of colon cancer will obviously not be the same. Staying for half an hour under the sun at 5pm while at the beach against staying for five hours under the sun from 11am-4pm; the risk of skin cancer is not the same. The radiation exposue that you receive from getting a CT scan once or twice a year in comparison to the dose that you would receive if you visit Chernobyl is, quite obviously, not the same.
The point being is that there’s always a dose response. There’s the dose, one cigarette per day, or 10 cigarettes per day; or the duration, smoking for one year in your whole life, or smoking for 40 years. It’s the same with red meat and colon cancer – eating it every day or once a week. There’s a different risk.
There’s no room for luck.
NE: Sorry for what may seem like an ignorant question, but is there any scientific data which shows that one’s own genetics plays a role in their susceptibility to cancer or the risk of eventually getting cancer?
DK: Yes, but we don’t understand much about hereditary cancer, which is only 5% of all cancer cases in human beings. That means only 5% of people, that we know of, got a gene from one of their parents that was mutated from the time of conception. That person will have a huge risk of getting cancer – breast cancer; colon cancer – at some point in their life. That is hereditary cancer.
95% of all cases, however, are what we call “sporadic cancer”. That’s without any known genetic connection. In the case of hereditary cancer, it’s the gene itself that will give you cancer, it’s that the gene is weak. So, if you are exposed to a carcinogen, you will most likely be at a higher risk because of the weak gene that you inherited.
NE: One’s own genetic make-up does play a part in the suceptability?
DK: Yes, of course, but we don’t know yet how to treat that. This is important, 80% of lung cancer occurs in people who smoke, but only 8% of smokers will actually develop lung cancer; 92% won’t.
We all know people in the countryside who drink a liter of red wine every day, plus some digestive after the meals, smoking several cigarettes without filters, and living until they’re 92
NE: Very true. My late wife’s close family friend – like an uncle, and who was a Crimean Tatar, his daily morning routine included a diet of rolled Soviet cigarettes, a shot of vodka, and a glass of kefir (fermented sheep’s milk). He lived well into his 90s.
DK: That’s interesting. You know, it’s a bit like the statistic that in Europe, there’s a 215% increase in the risk for lung cancer in non-smoking women over the last 15 years. We don’t understand why.
Ultimately, you ask people to stop smoking and do what you can to get young people to not smoke, but if they don’t want to stop, you have to help them find another way. We help bad drivers with seatbelts and ABS. We help bad eaters with Metformin for diabetes. We help people who like to sit in the sun on the beach with different types of cream and gels.
One of the best solutions for smokers is Snus (an oral smokeless tobacco product which is usually placed behind the upper lip,) sold in Scandinavia, where they have reduced the number of smokers to 5% It works best to help you stop smoking and it’s finally been approved in Europe and the United States.
Now we have electronic cigarettes, but there have been a lot of problems in the US because there was no regulation. You could buy E-cigarettes anywhere. When 400 people died there in two years ago in one summer, it was because whoever was selling the E-cigarettes put toxic chemicals into the device’s reservoir. In Europe, when E-cigarettes were commercialized, they were very regulated. Scandals like what happened in the US never happened in our countries.
You know, in the public health plans of some countries, in the UK, for instance, the NHS can now prescribe E-cigarettes as part of a health plan for smokers. I love that because it is effective to quit smoking. And it is not at all true that it promotes smoking amongst teenagers.Studies have shown that the uptake of young people taking up smoking because of E-cigarettes is only 1%.
NE: Do medical statistics show that regular smokers actually quit?
DK: Yes. They quit smoking combustible cigarettes. They do continue with their addiction to nicotine. But, and this is not widely known to the general public, the medical community and every doctor knows that nicotine has no toxicity for cancer. Not at all. It is purely a stimulant, just like caffeine. People smoke because they addicted to nicotine, but they’re dying because they get it from combustible cigarettes. If we can give them the nicotine without the combustion, that’s obviously better. SNUS does that and E-cigarettes do that, heated tobacco does that – each without any (significant measurable levels) of carcinogen.
Remember the dose/response relationship – the more carcinogen you get, the higher your risk of cancer. If you haven’t any combustion, which comes from the black smoke that contains all of the carcinogenic chemicals, and you replace it with white vapor, you have 95% less carcinogen. Those are statistics from organizations like the FDA and their counterparts in Europe and the UK.
The concept of harm reduction is fantastic, just like ABS for driving. For tobacco, innovations like SNUS, heated tobacco, and E-cigarettes – all are vastly better than smoking normal cigarettes. The problem that we have with bringing these harm reducing remedies to a wider public is that we’re dealing with very dogmatic people who refuse to look at the science. They don’t want to understand that everything that is less toxic is for the better.
NE: Is there the same hostility in the scientific community?
DK: No, no. Absolutely not. But the scientific community is afraid of being stigmatized for supporting electronic cigarettes and heated tobacco. I’ve been publicly attacked in my own country by scientists who are working with the anti-tobacco lobbies. But for me, what my goal for the rest of my life is to have young oncologists have less patients die from cancer. That’s my objective.