Published: 15 July 2020

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]

Published: 26 June 2020

Press Release - Friday, 26 June 2020

SOVAPE publish the first comprehensive document in France on vaping and smoking cessation during pregnancy

Smoking and pregnancy: should we really discourage vaping, at the risk of smoking?

In France more than half of pregnant women are unsuccessful in quitting smoking during their pregnancy. Faced with this major public health issue, SOVAPE have reviewed studies and scientific advice on the use of vaping as a tool to help quit smoking.

Difficult to stay the course among pregnant women

In conversation with INFO VAPE, a support group that is in daily contact with pregnant women, SOVAPE have noted recurring concerns about vaping. Those who smoke are discouraged from using vaping as an aid to quitting smoking, and those that have managed to quit by vaping are stigmatized, made to feel guilty, and “summoned” to stop vaping.

These “interventions” carried out by those around them, but also by doctors, midwives, obstetricians and gynaecologists, frequently lead to continued smoking or a relapsed to smoking. Why rule out one of the most effective smoking cessation tools available, when more than half (54.2%) of pregnant women who smoke are unsuccessful in their attempt to quit smoking by more traditional methods, according to data from Santé Publique France?

A document published today by SOVAPE, titled “Pregnancy and Vaping”, examines this issue. It is specifically intended for those women as well as their families and medical teams.

A review of studies available in 2020

In developing the document, SOVAPE has taken existing scientific literature, studies, and professional advice into account. As the inherent dangers of smoking are well established, adherence to precautionary principle clearly calls for the encouragement of pregnant women to stop smoking, which must include vaping.

A recent Cochrane review highlighted the influence of health professionals in attempts to stop smoking by pregnant women. When choosing nicotine substitutes and/or vaping, a significant psychological burden is placed on them. Discouraging the use of vaping, or even recommending its cessation, lessens the chances of successful cessation and can increases the risk of relapse for women who vape exclusively. The pressure exerted respects neither her freedom of choice nor the principle of "first do no harm".

A dangerous recommendation of the French National College of Gynaecologists and Obstetricians (CNGOF)

While carrying out our research SOVAPE discovered a CNGOF opinion piece published in January 2020. The document is of high quality when addressing the harms of tobacco, but it is problematic in that there is a lack of consideration of the available studies on vaping, and no differentiation is made between vaping products and tobacco products such as shisha and heated tobacco.

By recommending that women who have already stopped smoking by vaping should quit, the CNGOF contravenes the precautionary principle. This misguided recommendation greatly increases the risk of relapse to smoking, and in the opinion of SOVAPE, presents a clear danger to women and their children.

SOVAPE sent a letter to the CNGOF and its partners

SOVAPE sent a detailed letter to the CNGOF, as well as to the SFT (co-editor of the opinion), to Santé Publique France (patronage) and to all the organisations that co-signed the opinion piece. The consequences of making recommendations based on incomplete evidence is an increased potential for harm, as it could prolong smoking or cause relapse to smoking in women that had previously quit by using vaping. Considering the body of evidence, studies and expert opinion on this subject that have been neglected in the writing of the opinion piece, a re-examination of this piece is necessary. For the moment, one and a half months after this letter was sent, no organisation has responded.

Sources:

Link to INFO VAPE [link]

French version of this press release [link]

Full publication of SOVAPE "Vape and pregnancy" [link]

Advice from Dr. Marion Adler, tobacco specialist in smoking cessation assistance for pregnant women at Clamart Hospital since 2001 [link]

Advice from Dr. William Lowenstein, President of SOS-Addiction [link]

Published: 19 June 2020

ETHRA is delighted to publish this English translation of an article by Frank Baeyens, professor of psychology at the KU Leuven in Belgium and ETHRA scientific partner. This translation is for the French version, published in DH:
"Le gouvernement belge fait une grosse erreur en considérant que la cigarette électronique est aussi nocive que la cigarette classique"

A shorter Flemish version was published in HLN (paywalled):  “KU Leuven-professor over anti-tabaksdag: "Cordon sanitair rond nicotine helpt volksgezondheid niet vooruit. Overheid moet e-sigaret actief promoten”

The Belgian government's huge mistake

For several years now the number of smokers appears not to have decreased in Belgium. The current anti-tobacco policy does not seem to be accelerating the trend. If the Belgian government really wants to reduce the number of smokers quickly it must dare to embrace a wider strategy, one which includes tobacco and nicotine products. Simply discouraging smokers is not enough, because the most inveterate smokers do not respond positively. To get smokers to change their minds the government must dare to actively promote attractive alternatives that are less harmful to health, and even dare to promote electronic cigarettes. Keeping a cordon sanitaire around the consumption of nicotine in any form does not advance public health. On this World No Tobacco Day let's focus on the main objective, which is to help people quit smoking, rather than making it an anti-tobacco day.

Everybody knows that smoking is bad for your health. Everybody also knows that it is very difficult to stop smoking, partly because of the dependence creating effects of nicotine. There are a multitude of methods for quitting smoking but the new principle of "Tobacco Harm Reduction" (THR) is often a successful strategy. This principle encourages smokers to replace their cigarettes with nicotine products that present a proven low health risk, such as electronic cigarettes, nicotine patches or other nicotine replacement products. The method aims to significantly and quickly reduce the risks associated with the most harmful effects of smoking (such as cancer, cardiovascular disease, lung disease and the psychological damage caused by stigma or discrimination). The rest is less important. The fact that people continue to use nicotine is certainly much less worrying since nicotine is far less harmful in itself.

For THR to become widely adopted, people who want to quit smoking must be able to trust the safety of alternative nicotine products and to see these products as attractive alternatives. It is therefore essential to be able to communicate accurate and balanced information on the relative benefits and risks associated with these products. It is also essential to have an evidence based policy that reflects the differences in risks. Finally, it is up to the informed smokers to weigh the pros and cons and to opt, if they wish, for these alternative products.

Currently, the policy pursued by Belgium is more or less opposed to the principle of THR. The Belgian legislator considers electronic cigarettes and other less harmful alternatives as "similar to tobacco products" and has subjected them to the same strict restrictions, notably with regards to advertising. The latest legislative proposals are also going in this direction since the proposals include plain packaging for vaping products, labelling warnings against potential risks and significant limits on flavours - including proposals to ban all flavours except for tobacco.

Treating tobacco products and less harmful alternatives as the same in legal and political terms is absolutely not a good thing. Firstly, it reinforces the false impression that these two products are equally harmful. Why would a smoker opt for electronic cigarettes if they appear to be as harmful as traditional cigarettes, with no positive effect on their health? Secondly, this type of restrictive policy does not encourage smokers to turn to electronic cigarettes. It is currently impossible to inform smokers about the positive aspects for health through advertising, the product will be made less attractive - according to the plans of some - through bans on attractive flavours and packaging, vapers can only vape in areas provided for that purpose, and no product can be purchased on the internet. The predictable consequence is that smokers will continue to smoke, with all the negative effects that this has on their health.

A THR strategy aims to convince smokers who have failed to quit, or who do not wish to quit any kind of nicotine use, to vape rather than smoke. Many people fear that the over-the-counter sale of electronic cigarettes with various flavours will attract a multitude of young non-smokers who would then become addicted and then opt for the traditional cigarette. However, there is no indication to that effect, neither in Belgium nor in neighbouring countries, and, contrary to the assertions of some, this is not the case in the United States either. Many young people try vaping once or a few times but few choose to vape daily. If some continue it is unfortunate but it is generally because they were already smokers or had smoked before.

We must also dare to ask this: is it such a bad thing if young people start vaping, or continue to vape, if the numbers of young smokers decrease considerably? In countries where vaping is on the rise, we are seeing an accelerated and drastic decline in the number of young people who smoke.

Finally, it would be presumptuous to insist that someone who started smoking after starting vaping did so because the electronic cigarette had pushed them towards traditional tobacco products. The fact is that people who are more likely to vape are also more likely to start smoking traditional cigarettes, regardless of whether they have ever vaped or not.

Policy makers who want to include low-risk nicotine products in tobacco legislation are seeking to prevent a hypothetical or virtual problem. This would not be such a bad thing if it did not hinder the search for a solution to the really big and actual problem: the minimal decline in the percentage of +/- 20% of Belgian smokers and the billion smokers worldwide. I therefore hope that in the future the Health Commission will develop legislation which gives pride of place to the principle of THR in the strategy of discouraging smoking. The methods and strategies of "classic tobacco control" are useful, but their effects come too little and too late for many smokers.

Frank Baeyens is professor of psychology at KU Leuven in Belgium