January 2023. ETHRA submitted to the Netherlands consultation on the Nicotine products without tobacco Bill. The bill would regulate nicotine products without tobacco and nicotine devices under the Tobacco and Smoking Products Act. The Bill also proposes an outright ban on nicotine pouches.

Safer nicotine products are key to a successful tobacco control strategy

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 explanatory memorandum regarding the Bill amending the Tobacco and Tobacco Products Act regulating non-tobacco nicotine products and nicotine devices and are pleased to see that the government wants to support smokers who want to quit.

However, we are concerned that the proposed ban on nicotine pouches is misguided and will cause harm, as it will remove a viable low-risk alternative to smoking from the market.

As Professor Michael Russell pointed out in 1976, “people smoke for the nicotine but die from the tar.” The harms from smoking are due to the toxic products of combustion (the delivery method - smoking) and not from nicotine use. The Royal College of Physicians expanded upon this in its 2016 report, Nicotine without Smoke: “it is widely accepted that any long term hazards of nicotine are likely to be of minimal consequence in relation to those associated with continued tobacco use.”

Despite the Dutch government’s smoking prevention and awareness campaigns, the Trimbos Institute reports that the Netherlands had a smoking prevalence of 20.6% in 2021, an increase of 0.4% compared to 2020. According to KWF Kankerbestrijding, smoking remains one of the leading causes of preventable death, accounting for 20,000 premature deaths per year. Where traditional smoking cessation methods have failed, it is necessary and urgent to provide entrenched smokers with additional routes out of smoking. We in ETHRA - the people writing this - are living proof that where a range of appealing low risk alternatives is available it is possible for even the most dependent smokers to quit.

Over the last decade, innovations in the tobacco and nicotine marketplace has meant there are now many low-risk nicotine products available that do not involve combustion of the tobacco leaf and the inhalation of toxic smoke. These include vaping products, nicotine pouches, heated tobacco products, and low-nitrosamine smokeless tobacco, such as snus. Transitioning to low-risk nicotine products would provide substantial public health gains for people who smoke.

We appreciate there is a concern about potential youth use, however, the available data is reassuring on this point. An online survey of Dutch adolescents and adults, conducted by Havermans et al, found that among adolescents current use of nicotine pouches did not occur (0.0%) and ever use was 0.31%. The same study found that rates were highest in the 25 - 44 age group and concentrated among people who smoke. One of the main reasons this group was using pouches was to reduce or quit cigarettes.

The explanatory memorandum for the bill also raised concerns regarding tobacco specific nitrosamines (TSNAs). As nicotine pouches do not contain tobacco , the risk from TSNAs is minimal. The German Federal Institute for Risk Assessment (BfR) recently published a detailed health assessment of nicotine pouches. The analysis found that some pouches contained trace amounts of TSNAs at levels which were over 100 fold lower compared to unlit cigarettes. The BfR he report concluded that pouches can act as a harm reduction product for smokers.

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, a product similar to pouches in that it is also used orally, by people who would otherwise smoke. 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 and dispelled any notion that the use of snus acts as a gateway to smoking:

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.

An aim of the Bill, as set out in the Integrated Assessment Framework for Policy and Regulations (IAK), is to advance the goal of achieving a smoke free generation by 2040. In part thanks to the widespread use of snus, Sweden has almost reached this target: daily smoking prevalence is currently 5.8% and Sweden is on track to become a smoke free society this year.

The UK provides further evidence that tobacco harm reduction strategies and the use of safer nicotine products can be a driving force behind smoking cessation. A Cochrane systematic review of e-cigarettes for smoking cessation finds high certainty evidence that vapes are significantly more effective than nicotine replacement therapies (NRTs). The latest data from the UK’s Office for National Statistics (ONS) show that smoking prevalence has fallen to 13.3%, a historic low. The ONS stated that vaping has played a major role in the decline in smoking.

The role of e-cigarettes for smokers was also recognised by Trimbos in their guidance on e-cigarettes:

The e-cigarette appears to be somewhat effective as a smoking cessation aid. The success rates of quitting using an e-cigarette are similar to those of regular cessation methods, such as counselling or coaching, nicotine-replacement drugs and other medication.

It is therefore important to get the balance right when regulating safer nicotine products. The UK’s Royal College of Physicians warns against unintended consequences - excessive and burdensome regulation 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 want to stress that all safer nicotine products are crucial in helping smokers transition to a low-risk alternative to smoking. ETHRA has regularly engaged with NL ministers and parliamentarians to raise concerns and we also urge you to heed the warnings in ‘Regulation of e-cigarette flavours – a response’, a submission to the 2020 consultation signed by twenty-four scientific and policy experts.


A note on ETHRA’s preferred terms for products

As people with lived experience of using Safer Nicotine Products (SNPs), we generally choose to use these terms:
-‘vapes’, ‘vaping products’ and ‘vaping’, rather than ‘e-cigarettes’ or ‘ENDS’.
-‘HTPs’ to refer to Heated Tobacco Products.
-‘Nicotine pouches’ for non-tobacco containing oral sachets.
-‘snus’ to refer to the pasteurised Scandinavian oral tobacco product, either in loose or pouch form.


Download our submission here

Access our submission on the consultation page here