October 2022. ETHRA wrote to the Belgian government to highlight the important role safer nicotine products can play in its upcoming inter-federal strategy for a smokefree generation. The letter was co-signed by 19 independent experts in tobacco and nicotine science and policy.

Dear Ministers,

Safer nicotine products should play a much bigger role in the Inter-Federal Strategy for a smokefree generation

We write as the European Tobacco Harm Reduction Advocates (ETHRA) and 19 co-signed independent experts in tobacco and nicotine science and policy. The signatories to this letter report no conflicts of interest with respect to the tobacco or vaping industries.

European Tobacco Harm Reduction Advocates is the voice of 27 million EU consumers of safer nicotine products. ETHRA is a consortium of 25 grassroots consumer associations in 17 European countries, supported by experts in tobacco control and nicotine research. We are mostly ex-smokers who have used safer nicotine products, such as vapes, nicotine pouches, heated tobacco products, and snus, to quit smoking and to remain smoke free. ETHRA is a voluntary operation with no industry funding or conflicts of interest. Our EU Transparency Register number is 354946837243-73.

We have read with interest the Inter-federal Strategy for a smokefree generation and are pleased to see that the group recognises that the problem with tobacco use is smoking.

As Professor Michael Russell pointed out in 1976, “people smoke for the nicotine but die from the tar.”

Despite all the government’s smoking prevention and awareness campaigns, Sciensano reports that in 2018, 1 in 5 Belgians still smoke. According to the Foundation against Cancer, 14000 Belgians die every year from smoking related diseases. It is necessary and urgent to provide these smokers with a route out of smoking.

Over the last decade, innovations in battery technology and in the tobacco and nicotine marketplace has meant there are now many nicotine products available that do not involve combustion of the tobacco leaf and inhalation of smoke. These include vaping products, nicotine pouches, heated tobacco products, and low-nitrosamine smokeless tobacco, such as snus.

The role of some of these safer nicotine products was recognised by Belgium’s Superior Health Council in their report on Heated Tobacco Products and most recently on electronic cigarettes.

The relative risk of e-cigarettes compared to smoking is also clear: e-cigarettes are considered substantially less harmful than smoking. They represent a better alternative to smoking for smokers and can be used as a smoking cessation aid
Translated by ETHRA

Furthermore, the German Federal Institute for Risk Assessment (BfR) recently published a detailed health assessment of nicotine pouches acknowledging that pouches are low risk products which may aid smoking cessation.

Taking into account this concept of harm reduction, switching from cigarettes to nicotine pouches could represent a reduction in the health risk for a person who smokes.

The BfR report also acknowledges the harm reduction potential of snus. Citing Ramström et al (2016) it notes that Swedish men have been using snus as a substitute for smoking for decades. This has led to dramatic public health gains:

Snus has both contributed to decreasing initiation of smoking and, when used subsequent to smoking, appears to facilitate smoking cessation. All these effects suggest that the availability and use of snus has been a major factor behind Sweden’s record-low prevalence of smoking and the lowest level of tobacco-related mortality among men in Europe.

The US Food and Drug Administration conducted an extensive evaluation of over two million pages of evidence for a heated tobacco product made by a major tobacco company. The FDA concluded the product is “appropriate for the protection of public health” and disclosing to the public that it created significantly lower human exposures to toxicants is “appropriate for the promotion of public health”.

Fifteen past presidents of the leading professional academic society in the field, the Society for Research on Nicotine and Tobacco (SRNT), wrote a scientific essay arguing for a rebalancing in tobacco policy to exploit opportunities from safer nicotine products. The authors, some of the most credible experts globally, address many misconceptions regarding risks to health, gateway effects, youth use, and addiction. The paper concludes:

While evidence suggests that vaping is currently increasing smoking cessation, the impact could be much larger if the public health community paid serious attention to vaping’s potential to help adult smokers, smokers received accurate information about the relative risks of vaping and smoking, and policies were designed with the potential effects on smokers in mind. That is not happening.

It is therefore important to get the right balance in regulation of safer nicotine products vis-à-vis combustible cigarettes. As highlighted by the UK’s Royal College of Physicians, excessively burdensome regulation (including prohibition) applied to safer nicotine products could lead to more smoking.

However, if [a risk averse, precautionary] approach also makes e-cigarettes less easily accessible, less palatable or acceptable, more expensive, less consumer friendly or pharmacologically less effective, or inhibits innovation and development of new and improved products, then it causes harm by perpetuating smoking. Getting this balance right is difficult.

We therefore ask you to take ETHRA’s manifesto into consideration when considering tobacco policy:

  1. Access to harm reduction, including tobacco harm reduction, must be recognised as a human right.
  2. Consumers of safer nicotine products must be recognised as essential stakeholders in discussions of policy.
  3. Regulation for safer nicotine products must reflect the risks relative to the risks from smoking.
  4. Regulators must recognise that having a wide choice of products and flavours is key to the success of safer nicotine products in enabling people to stop smoking.
  5. Regulators must consider the harm to adults when considering measures intended to protect youth.
  6. Tax policy must take into account that high taxation of safer nicotine products deters smokers from switching.

These points will help in creating a coherent risk-based framework for all nicotine products.

We do hope this input will inspire the government’s Inter-federal Strategy for a smokefree generation as this strategy will be crucial to decreasing death and disease from smoking.

We would welcome the opportunity to discuss these ideas with you and provide more information.

Yours sincerely,

Read the full letter with signatures and references here