There should be a debate within the Czech Republic and the EU on the division of nicotine products according to harmfulness. "It is almost a crime not to broach this topic just because it is politically difficult. People are dying because of it," says National Anti-Drug Coordinator Jindřich Vobořil. Photo: Stanislav Pecháček

It is almost a crime not to raise the topic of tobacco harm reduction at the EU level just because it is politically difficult, says Jindřich Vobořil

Compared to many other countries, Czech drug policy boasts a unified approach to different types of addiction, for which it consistently chooses the approach of risk minimization. Both the current government, which has included harm reduction policy in its government declaration, and the returning national anti-drug coordinator, Jindřich Vobořil, wish to move this approach forward. For example, he said, there should be a discussion about the possibility of a regulated cannabis market, because it is questionable whether it would have better results than prohibition in this case. Another crucial issue is considering the harmfulness level of tobacco and nicotine products, an issue which, according to Vobořil, can have fatal consequences for many people if ignored by politicians. The issue was the subject of the 2nd Annual International Panel of the Permanent Conference on Healthcare, which took place on 6 September in Prague.

„Addiction is one of the top five preventable issues in public health and medicine. In the Czech Republic alone, 14,000 people die prematurely because of smoking, and I could go on. Years ago, we said that we needed to integrate policies – because addictions are intertwined. If you look at the ESPAD study, which focuses on the abuse of different types of substances by 16-year-olds, you would be surprised at how high tobacco use is intertwined with the abuse of other addictive substances, not only alcohol, but also illicit ones,“ says Vobořil.

According to some studies, people who start using tobacco before their 16th birthday are up to eight times more likely to develop an addiction to illicit drugs. In the Czech Republic, therefore, in addition to a unified policy on addiction to tobacco, alcohol, illegal drugs and gambling, summarised in the National Strategy for the Prevention and Reduction of Harm Associated with Addictive Behavior, we also have a National Anti-Drug Coordinator, who reports directly to the Prime Minister and whose remit is supra-ministerial. In order to tackle addiction, there is need not only for healthcare but also social services, alcohol and tobacco price regulation, education, the police, customs, and the judicial system.

But setting up evidence-based policy is not easy. „Sometimes we look at the same numbers but have opposite interpretations. So, when based on evidence, it is not easy to say what should happen when working with the public, teenagers, and policies. We have some evidence and we know which way to go, but it is shrouded in so many myths that it is very difficult to enforce rationality,“ says Jindřich Vobořil.

In the end, there are two main paths in addiction policy – either it focuses on abstinence (and it is questionable to what extent a world without alcohol, tobacco, caffeine, or gaming is an unrealistic utopia), or it will be a harm reduction policy that will aim to reduce risks across the spectrum. This is the attempt to balance prevention with regulation and justice in a coordinated way.

Public opinion versus evidence

The Czech strategy, which has chosen the path of risk reduction, has been developed for the years 2019 to 2027, and is subsequently being developed into action plans. The strategy has five main objectives, which are to strengthen prevention and raise awareness, to ensure a high quality and accessible network of addiction services, to effectively regulate the markets for addictive substances and addiction products, to strengthen the management, coordination and effective financing of drug policy, in addition to special topics such as psychoactive medicines, the exploitation of the internet and new technologies, and the issue of cannabis and cannabinoids.

This is a policy that the current government has already decided to support in its government statement, where it promises that „in addressing the issue of addiction, we will pursue a policy based on a scientifically proven and balanced approach to risk prevention and harm reduction, ensuring that prevention programmes and services, and the regulation of addictive substances, are adequately funded to reflect their level of harm.“ This approach was also the reason why Jindřich Vobořil, who left the post of national anti-drug coordinator in 2018, decided to accept the offer to return to the post.

The session entitled „The role of an interdisciplinary approach in public health policymaking (key actors, awareness raising, public opinion),“ from left: Leonard Savage, Creative Director, McCann Worldgroup, Piotr Jablonski, National Anti-Drug Coordinator, Poland, Jindřich Vobořil, National Anti-Drug Coordinator, Czech Republic, Ján Mikas, Chief Medical Officer of the Slovak Republic, Tomáš Cikrt, Editor-in-Chief of Zdravotnický deník, Richard Raši, Member of the National Assembly of the Slovak Republic, former Deputy Prime Minister and Minister of Health of the Slovak Republic, Ivan Duškov, Deputy Director of the General Health Insurance Company, and Martin Smatana, Chairman of the Supervisory Board of the Slovak General Health Insurance Company.

Of course, distinguishing the level of harm is not a simple task and, in addition to the level of evidence, public opinion is also very much influenced by the view on this issue. This often goes against evidence, which, in turn, can make political decisions difficult.

„It is not easy for the Minister of Health or the Prime Minister to stand up and say: evidence tells us that this kind of heavy-handed regulation has not gotten us anywhere, so we want to create a regulated market, for example with cannabis, now on the table in the Czech Republic. Or there is the subject that is a little simpler but also complex, that being the regulation of nicotine sachets. We cannot agree on that, even though the evidence is clear from our point of view, but the mood around us varies,“ Vobořil says.

We distinguish according to harmfulness

The question of the greater differentiation between tobacco and nicotine products according to their level of harm is now on the table in several countries. The risks of using e-cigarettes are fractional compared to those of smoking conventional cigarettes. Nicotine is not at the heart of health problems, but the combustion and inhalation of the substances contained in a cigarette are.

„Even within the EU, we are now opening up the debate on the Tobacco Directive, and I am convinced that it is almost a crime not to broach this topic just because it is politically difficult. People are dying because of it,“ Vobořil emphasizes.

Cannabis is also controversial, but due to the emotions it arouses, it remains a relatively minor topic in terms of the number of users – while there are around two million daily cigarette smokers, there are 27,000 daily cannabis users in our country. In addition, for example, unlike alcohol (which is consumed daily by almost one million people in the Czech Republic, of which and 160,000 drink excessively), cannabis use is not associated with minor crime or domestic violence.

Another challenge is gambling, which, unlike alcohol, is the responsibility of DG SANCO within the EU; whereas tobacco, falling under agriculture or illegal drugs, in turn falls under justice and internal affairs, is not the responsibility of anyone in the EU. For a long time, this was also the case in the Czech Republic, but now the Ministry of Finance plays the dominant role of regulator.

Let us not forget the situation in Ukraine

The National Anti-Drug Coordinator should soon present the topics we should now address in addiction policy in the framework of the upcoming Action Plan for 2022-2024. In addition to supporting the prevention and treatment of addiction or effective tax collection and pricing, the regulated market for addictive substances, especially cannabis, should be a priority. „The question is whether the regulated market offers more tools for prevention than prohibition itself,“ Vobořil points out.

The plan also includes promoting the priorities of the Czech EU Presidency and minimizing the impact of the crisis in Ukraine on the situation in the area of addiction. „Many people come to us who have an addiction problem, and we know that this is linked to other negative phenomena such as hepatitis C, HIV, and other communicable diseases. Ukraine has about two percent of illegal drug users, while ours is about half a percent. Incidence and prevalence is therefore significantly higher there,“ adds Jindřich Vobořil.

Michaela Koubová

Addiction was not the only issue discussed at the 2nd Annual International Panel of the Permanent Conference on Healthcare, which took place on 6 September in Prague.