Here we publish the letter we sent to the Dutch Health Minister Mr Blokhuis and to the Parliament yesterday, to protest against the proposed ban on e-liquid flavours. The letter is signed on behalf of ETHRA and Acvoda by Sander Aspers, Acvoda’s Chair and is also signed by ETHRA’s scientific partners.
You can read about the Dutch proposals in the government press release here. The reasoning behind the flavour ban? It is the same baseless assumption that has been made in other countries, that the sole purpose of flavouring in e-liquid is to attract youth. Yet again there was no regard given to the devastating impacts such a preposterous decision would have on adult ex-smokers who rely on flavoured e-liquid in e-cigarettes to remain smoke free, or the impacts such a move would have on future cessation efforts, given that vaping is the most popular and effective method of smoking cessation available.
There is a petition against the ban, please sign and share it if you can :
Stop het verbod op e-liquids met smaakjes / Stop the ban on flavoured e-liquids
https://petities.nl/petitions/stop-het-verbod-op-e-liquids-met-smaakjes?locale=en
ETHRA letter to Health Secretary Mr Blokhuis
14 July 2020
Dear Mr Blokhuis,
We are very proud to represent Dutch consumers too, as Acvoda is one of our partners, and Sander Aspers, Chair of Acvoda, has signed this letter on behalf of all of us. ETHRA is listed in the EU Transparency Register at: 354946837243-73.
We are writing today in response to the announcement that the Netherlands intends to ban flavours for e-cigarettes, with the exception of tobacco flavour. We saw in the press release (2) that this is in response to concerns about youth initiation and we thought we should outline some reasons as to why we feel this ban is inappropriate.
Vaping is successful at helping adult smokers - like so many of us - to quit. This is borne out by data from Belgium, France, Ireland and the UK (3). Having a wide variety of flavours is intrinsic to the success of vaping products: the ability to tailor vaping to individual tastes plays a very important role in its effectiveness at drawing people away from smoking. The evidence in this area is clear, showing that whilst many people start vaping with a tobacco flavour, over time they gravitate towards fruit, dessert and sweet flavours (4).
A recent study published in JAMA (5) concludes that “adults who began vaping non-tobacco flavored e-cigarettes were more likely to quit smoking than those who vaped tobacco flavors.”
The same study also found that flavours are not associated with youth smoking initiation: “Relative to vaping tobacco flavors, vaping non tobacco-flavored e-cigarettes was not associated with increased youth smoking initiation but was associated with an increase in the odds of adult smoking cessation.”
Research by RIVM (6) emphasises that flavours in e-cigarettes contribute to users switching completely to e-cigarettes and recommends that: “Ideally, regulation should allow marketing of e-liquid flavors that stimulate smokers and dual users to keep or start using e-cigarettes.”
Banning or restricting flavours will have a disastrous effect on smoking cessation, effectively removing the products responsible for huge reductions in smoking prevalence from the market. Non tobacco flavours help to disassociate smokers from the taste of tobacco and so lessen the chances of relapse to smoking.
The added danger with limiting or banning flavours is that consumers are then forced to use the black market to obtain the product they need. This was the experience in Estonia where a flavour ban and high taxation led to an explosion of black-market products, reported to account for 62-80% of all sales (7). In response, Estonia recently amended its legislation and now allows menthol flavour to be sold.
States in the USA that have banned flavours have also seen thriving black markets develop as ex-smokers seek out the only products that have successfully kept them smoke free. Black market sales of flavoured vaping products are reported (8) to be a regular occurrence in car parks around Long Island New York. Prohibition hasn’t eliminated the product; it has simply driven it underground and criminalised those whose only crime is wanting to remain free from cigarette smoking.
There are also health risks associated with banning flavours, as consumers turn to unregulated products or mix their own e-liquids with food flavourings not suited for vaping. Oil based flavours in particular could present a significant health hazard. Inexperienced vapers driven to mix their own flavoured liquids may not be aware that e-liquid flavourings are water soluble, and in their desperation could add oil-based food flavourings to their liquids, without realising the inherent danger this poses.
A study (9) looking at the impacts of a flavour ban in California found that while flavour bans may reduce overall use of vapour products they also may increase cigarette smoking. Comparing before and after the ban, cigarette smoking increased in 18 to 24-year olds from 27.4% to 37.1%.
We appreciate that there are concerns about youth initiation but there is no evidence that non-smoking young people are becoming dependent on vaping nor that vaping is leading to young people smoking.
Recently published Jongeren en riskant gedrag (10) from TRIMBOS shows that in the Netherlands youth smoking rates are low and continue to decline, from 2.1% in 2017 to 1.8% in 2019. Jongeren en riskant gedrag also shows that youth vaping is in decline:
“Between 2015 and 2019 there was a decrease in the percentage of young people aged 12 to 16 who have ever used an e-cigarette; from 34% in 2015 to 25% in 2019.” (p. 81)
The Netherlands has therefore performed exceptionally well in regards to youth smoking and vaping, as prevalence is low and moving downwards for both.
We are therefore surprised and concerned to see the Trimbos Institute’s (11) statement that Dutch health will benefit most from discouraging e-cigarettes, as it is adult smokers who will be adversely affected by these measures. Adult smoking prevalence in the Netherlands is high (12), at 21.7%. This 21.7% represents a lot of people who could benefit greatly from switching to a less harmful product. Vaping is far less risky to health than smoking, the UK Royal College of Physicians stated in its 2016 report Nicotine Without Smoke (13) that:
“the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure”. See section 5.5 page 87
There are no circumstances in which it is better to smoke than to vape and so keeping vaping products attractive for smokers, to encourage them to switch, can only be a win for public health. Having a wide variety of flavours is crucial to vaping’s success at winning over dependent smokers.
We share your commitment to health prevention and promotion but fear that banning flavours will not serve that purpose.
Yours sincerely,
Sander Aspers
Chair of Acvoda, ETHRA Partner
ETHRA’s scientific partners also fully endorse this letter:
Frank Baeyens, PhD
Professor Faculty of Psychology and Educational Sciences KU Leuven. Belgium.
Jacques Le Houezec, PhD
Scientist - Smoking Cessation Specialist - Trainer, Rennes, France.
Bernd Mayer, PhD
Professor & Chair Department of Pharmacology and Toxicology. University of Graz. Austria.
Lars M Ramström, PhD
Institute for Tobacco Studies. Ingemarsgatan. Sweden.
Andrzej Sobczak, PhD
Head of the Department of General and Inorganic Chemistry. School of Pharmacy with the Division of Laboratory Medicine. Medical University of Silesia. Poland.
REFERENCES
1. Estimate of 27 million consumers provided by ECigIntelligence/TobaccoIntelligence. The actual figure is likely to be far higher because the data for smokeless tobacco is taken from research (Leon et al 2016) using data gathered in 2010 in only 17 countries.
2. Smaakjes van e-sigaretten worden verboden Nieuwsbericht 23-06-2020 [access]
3. Interview on Tobacco Products Directive: notes by ETHRA, pps 8-9 Impact of e-cigarettes on smoking cessation [access]
4. Russell C, McKeganey N, Dickson T, Nides M. Changing patterns of first e-cigarette flavor used and current flavors used by 20,836 adult frequent e-cigarette users in the USA. Harm Reduct J. 2018 Jun 28;15(1):33 [access]
5. Friedman AS, Xu SQ. Associations of Flavored e-Cigarette Uptake With Subsequent Smoking Initiation and Cessation. JAMA Netw open. 2020 Jun 1;3(6):e203826 [access]
6. KA Romijnders, Erna JZ Krüsemann, Sanne Boesveldt, Kees de Graaf, Hein de Vries, Reinskje Talhout. E-Liquid Flavor Preferences and Individual Factors Related to Vaping: A Survey among Dutch Never-Users, Smokers, Dual Users, and Exclusive Vapers. Int J Environ Res Public Health. 2019 Dec; 16(23):4661 [access]
7. Baltic Times, Estonian FinMin looking into prospect of lowering excise duty for e-cigarettes 25 Nov 2019 [access]
8. Filter, Vape Bans Are Creating a Thriving Illicit Market 8 July 2020 [access]
9. Yong Yang, Eric Lindblom, Ramzi Salloum, Kenneth Ward. The impact of a comprehensive tobacco product flavor ban in San Francisco among young adults. Addict Behav Rep. 2020 Jun; 11: 100273 [access]
10. Jeugd en riskant gedrag 2019, Trimbos Institute [access]
11. Risico’s gebruik e-sigaret in kaart gebracht, Trimbos Institute [access]
12. Cijfers roken, Trimbos Institute [access]
13. Royal College of Physicians (London), Nicotine without smoke: tobacco harm reduction, April 2016 [access]
LINKS:
Acvoda [LINK]
This letter [LINK]