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ETHRA has made a submission to the Netherlands Ministry of Health, Wellbeing and Sports’ public plain packaging consultation, which ended last Friday. The purpose of the draft legislation is to “set requirements by ministerial regulation for the standard packaging of cigars and electronic vapor goods.” If enacted the legislation will see plain packaging requirements, which are currently applied to combustible tobacco products, also applied to products which are far less risky to health, such as vaping products.

The rationale for the proposed legislation is the usual “think of the children” rhetoric, stating the need to protect young people from smoking. This is despite youth smoking rates continuing to fall in The Netherlands. Predictably, no thought has been given to the plight of smokers who could greatly benefit from switching to vaping products. Nor has consideration been given to the consequences of misleading smokers by requiring safer products to have plain packaging – and so implying that safer nicotine products are as harmful to health as combustible products.

This gross miscommunication of the relative risks of vaping compared to smoking will cause more smoking. If accepted, this legislation will set a dangerous precedent that could spread to the rest of the EU and so it should be strongly resisted.

 

ETHRA’s submission to verhittingsapparaten en standaardverpakkingen e-sigaretten en sigaren

Thank you for the opportunity to comment on these proposals. Our contribution outlines why applying neutral packaging to safer alternatives to smoking would be detrimental to Dutch public health.

First, a quick note about who we are: European Tobacco Harm Reduction Advocates (ETHRA)1 is a group of 22 consumer associations in 16 European countries, representing approximately 27 million consumers across Europe2 and supported by scientific experts in the field of tobacco control or nicotine research. We are mostly ex-smokers who have used safer nicotine products, such as vapes and snus, to quit smoking and to remain smoke free. We are very proud to represent Dutch consumers too, as Acvoda3 is one of our consumer group partners. ETHRA is not funded by the tobacco or vaping industry, in fact we are not funded at all as our grouping is a voice for our partners who arrange their own revenue and who give their time to ETHRA for free. Our mission is to give consumers of safer nicotine products a voice and to ensure that the full harm reduction potential of safer nicotine products is not hindered by inappropriate regulation.

We feel that the reasoning for these proposals4 as applied to safer alternatives to smoking are not underpinned by science.

The stated aim of the proposals is to protect young people from smoking and the explanatory note says that use of e-cigarettes by young people is “considerable”. However, the latest Trimbos data does not bear this out and we find it interesting that the explanatory note does not include this data. This, from Jongeren en riskant gedrag5 shows that youth vaping is actually 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.”

There is no evidence that vaping is leading young people to smoking, in the Netherlands or elsewhere. In the Netherlands youth smoking rates are low and continue to decline, from 2.1% in 2017 to 1.8% in 20196. In the USA, analysis of the most recent National Youth Tobacco Survey found that frequent use of vaping products was rare among never smokers. US youth smoking continues to drop, falling from 8.1% in 2018 to 5.8% in 20197.

The explanatory note states that e-cigarettes are harmful. This is highly misleading. It has been known for decades that people smoke for the nicotine but die from the tar8. Since the use of safer nicotine products doesn’t involve combustion, there is no tar. In fact, vaping is at least 95% less harmful than smoking9. A recent review10 from the UK’s Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment (COT) concluded that smokers who switch completely to vaping will get a substantial health benefit and that there is a considerable reduction in the risk of lung cancer due to lower exposure to harmful compounds.

The explanatory note states that the government does not consider e-cigarettes to be effective for smoking cessation. This is not correct as there is robust evidence showing that vaping leads to quitting smoking11 and smoking prevalence is dropping in countries where safer alternatives to smoking have been widely adopted12. In an analysis of 8 European member states, the Netherlands was found to have the best long-term quitting success rate for smokers using e-cigarettes13.

By seeking to solve a non-existent problem (youth vaping), the proposals fail to take the actual problem (adult smoking) into account. It is adult smokers who will be adversely affected by these measures. Adult smoking prevalence in the Netherlands is high, at 21.7%14. This 21.7% represents a lot of people who could benefit greatly from switching to a less harmful product. Adult smokers should be entitled to take steps to improve their own health but concealing and misrepresenting the safer alternatives will prevent them from doing that. Adult smokers are far more likely to suffer smoking related disease and death than young smokers and their interests should be taken into account. A focus on adult smoking also has benefits for youth, as youth are more likely to smoke if their parents smoke15.

Here we will outline why plain (or neutral) packaging for vaping products will deny adult smokers the right to improve their own health and so will prolong smoking.

Treating safer nicotine products in the same way as harmful combustible cigarettes sends the wrong message that the products are equally as harmful. This discourages people from switching, which results in more smoking. Tragically, the misperception that e-cigarettes are as harmful as combustible tobacco products is growing16 amongst smokers and the proposals in this bill will contribute to that.

E-cigarettes are new products and it is critical that adult smokers can be informed about these innovative products and receive non-misleading information about their risk in relation to combustible tobacco products. E-cigarettes are competing with combustible cigarettes, but it is not a level playing field: everyone already knows what combustible cigarettes are and how to use them.

Access to information about these new products is already restricted, as The Tobacco Products Directive (TPD) prohibits most forms of advertising. So, it is crucial that the product packaging can convey information and that consumers can see this information in order to choose which product to buy. E-cigarettes are much more complicated to use than combustible cigarettes and there are many different types, how can consumers use these safer alternatives without access to information about them? Ideally, smokers should be incentivised to use something which is better for them and it would be a win for public health if accurate evidence-based information could be communicated on product packaging17.

The TPD mandated health warnings which are displayed on vaping products hugely overstate the risks of using e-cigarettes and deter smokers from switching18. These off- putting health warnings will be even more prominent if the neutral packaging proposals are applied.

The justification for applying plain packaging restrictions to combustible cigarettes rests on the harms done by smoke and the high risks to health. There is no such basis for applying the restrictions to products which reduce harm.

As well as being inimical to public health we feel that these measures are unnecessary: there is already a ban on the sale of nicotine products to under 18’s and display bans are also in place.

We appreciate that there are concerns about youth initiation, but these concerns are not borne out by the evidence. The National Prevention Agreement is misusing the precautionary principle19 by seeking to protect youth from an illusory threat at the expense of adult smokers, for whom the harms are very real.

ETHRA is registered on the EU Transparency Register, registration number 354946837243-73

 

Sources

(1) European Tobacco Harm Reduction Advocates [access]

(2) 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

(3) Acvoda. Actief Voor Dampen [access]

(4) Verhittingsapparaten en standaardverpakkingen e-sigaretten en sigaren [access]

(5) Jeugd en riskant gedrag 2019, Trimbos Institute [access]

(6) Jeugd en riskant gedrag 2019, Trimbos Institute [access]

(7) Martin Jarvis, Sarah Jackson, Robert West, Jamie Brown. (2020). Epidemic of youth nicotine addiction? What does the National Youth Tobacco Survey 2017-2019 reveal about high school e-cigarette use in the USA? Qeios [access]

(8) Britton J. E-cigarettes and the precautionary principle. BMJ Opinion. 20 Sept 2019 [access]

(9) Public Health England, Evidence review of e-cigarettes and heated tobacco products 2018 A report commissioned by Public Health England, February 2018 [access]

(10) Committee on toxicity of chemicals in food, consumer Products and the environment. Statement on the potential toxicological risks from electronic nicotine. September 2020 [access]

(11) Hajek P, Phillips-Waller A, Przulj D, Pesola F, Myers Smith K, Bisal N, et al. A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy. N Engl J Med. 2019 Feb 14;380(7): NEJMoa1808779 [access]

(12) Interview on Tobacco Products Directive: notes by ETHRA, pps 8-9 Impact of e-cigarettes on smoking cessation [access]

(13) Hummel K, Nagelhout GE, Fong GT, et al. Quitting activity and use of cessation assistance reported by smokers in eight European countries: Findings from the EUREST-PLUS ITC Europe Surveys. Tob Induc Dis. 2018;16(Suppl 2): A6. doi:10.18332/tid/98912 [access]

(14) Cijfers roken, Trimbos Institute [access]

(15) Leonardi-Bee J, Jere ML, Britton J. Exposure to parental and sibling smoking and the risk of smoking uptake in childhood and adolescence: a systematic review and meta-analysis. Thorax 2011; 66:847-855 [access]

(16) Public Health England. Vaping in England: 2020 evidence update summary. March 2020 [access]

(17) Communicating the relative health risks of E-cigarettes: An online experimental study exploring the effects of a comparative health message versus the EU nicotine addiction warnings on smokers' and non-smokers' risk perceptions and behavioural intentions [access]

(18) Cox S, Frings D, Ahmed R, Dawkins L. Messages matter: The Tobacco Products Directive nicotine addiction health warning versus an alternative relative risk message on smokers’ willingness to use and purchase an electronic cigarette. Addict Behav Rep. 2018; 8:136-139 [access]

(19) The Counterfactual. Ten perverse intellectual contortions: a guide to the sophistry of anti-vaping activists. Clive Bates. April 2018. [access]