European Tobacco Harm Reduction Advocates

: Published: 13 November 2020

ETHRA letter to Dutch Health Minister Mr Blokhuis

July 2020. ETHRA wrote to Dutch Health Minister Mr Blokhuis and to the Dutch Parliament, to protest against the proposed e-liquid flavour ban.

Dear Mr Blokhuis,

European Tobacco Harm Reduction Advocates (ETHRA) is a group of 21 consumer associations in 16 European countries, representing approximately 27 million ⁱ consumers across Europe 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. 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 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 releaseⁱⁱ 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 UKⁱⁱⁱ. 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 ^iv.

A recent study published in JAMA^v 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^vi 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^vii. 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^viii 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^ix 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^x 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 statementxi 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^xii, 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^xiii 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,
Tiensestraat 102 - box 3712
3000 Leuven
Belgium

Jacques Le Houezec, PhD
Scientist - Smoking Cessation Specialist - Trainer, Rennes, France.
Amzer Glas
176 rue de Brest
35000 Rennes
France

Bernd Mayer, PhD
Professor & Chair
Department of Pharmacology and Toxicology
University of Graz
Humboldtstr. 46
A-8010 Graz
Austria

Lars M Ramström, PhD
Institute for Tobacco Studies
Ingemarsgatan 4 B
SE-11354 Stockholm
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. Jagiellońska 4 41-200 Sosnowiec, Poland

ⁱ 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

ⁱⁱ Smaakjes van e-sigaretten worden verboden Nieuwsbericht 23-06-2020 [access]

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

^iv 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]

^vFriedman 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]

^vi 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]

^vii Baltic Times, Estonian FinMin looking into prospect of lowering excise duty for e-cigarettes 25 Nov 2019 [access]

^viii Filter, Vape Bans Are Creating a Thriving Illicit Market 8 July 2020 [access]

^ix 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]

^x Jeugd en riskant gedrag 2019, Trimbos Institute [access]

^xi Risico’s gebruik e-sigaret in kaart gebracht, Trimbos Institute [access]

^xii Cijfers roken, Trimbos Institute [access]

^xiii Royal College of Physicians (London), Nicotine without smoke: tobacco harm reduction, April 2016 [access]

You can download our letter here (PDF)

ETHRA submission for the NL plain packaging consultation.

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 offputting 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 https://ethra.co/

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 https://acvoda.nl/

⁴ Verhittingsapparaten en standaardverpakkingen e-sigaretten en sigaren https://www.internetconsultatie.nl/standaardverpakkingen

⁵ Jeugd en riskant gedrag 2019, Trimbos Institute https://www.trimbos.nl/kennis/cijfers/alcohol-drugs-roken-scholieren

⁶ Jeugd en riskant gedrag 2019, Trimbos Institute https://www.trimbos.nl/kennis/cijfers/alcohol-drugs-roken-scholieren

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. https://www.qeios.com/read/745076.5

⁸ Britton J. E-cigarettes and the precautionary principle. BMJ Opinion. 20 Sept 2019 https://blogs.bmj.com/bmj/2019/09/20/john-britton-electronic-cigarettes-and-the-precautionary-principle/

⁹ Public Health England, Evidence review of e-cigarettes and heated tobacco products 2018 A report commissioned by Public Health England, February 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/684963/Evid ence_review_of_e-cigarettes_and_heated_tobacco_products_2018.pdf

¹⁰ Committee on toxicity of chemicals in food, consumer Products and the environment. Statement on the potential toxicological risks from electronic nicotine. September 2020 https://cot.food.gov.uk/sites/default/files/2020-09/COT%20E%28N%29NDS%20statement%202020-04.pdf

¹¹ Hajek P, Phillips-Waller A, Przulj D, Pesola F, Myers Smith K, Bisal N, et al. A Randomized Trial of ECigarettes versus Nicotine-Replacement Therapy. N Engl J Med. 2019 Feb 14;380(7): NEJMoa1808779 https://www.nejm.org/doi/full/10.1056/NEJMoa1808779

¹² Interview on Tobacco Products Directive: notes by ETHRA, pps 8-9 Impact of e-cigarettes on smoking cessation https://ethra.co/images/ETHRAs_notes_on_TPD_interview.pdf

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 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6659556/

¹⁴ Cijfers roken, Trimbos Institute https://www.trimbos.nl/kennis/cijfers/cijfers-roken

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 https://pubmed.ncbi.nlm.nih.gov/21325144/

¹⁶ Public Health England. Vaping in England: 2020 evidence update summary. March 2020 https://www.gov.uk/government/publications/vaping-in-england-evidence-update-march-2020/vaping-inengland-2020-evidence-update-summary

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 https://pubmed.ncbi.nlm.nih.gov/31753541/

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 https://www.sciencedirect.com/science/article/pii/S235285321830138X

¹⁹ The Counterfactual. Ten perverse intellectual contortions: a guide to the sophistry of anti-vaping activists. Clive Bates. April 2018. https://www.clivebates.com/ten-perverse-intellectual-contortions-a-guide-to-the-sophistry-of-anti-vapingactivists/#s4.

ETHRA submission for the NL plain packaging consultation.

September 2020. ETHRA submitted to the Netherlands Ministry of Health, Wellbeing and Sports’ public plain packaging consultation.

You can download our submission here (PDF)

The Netherlands https://ethra.co/submissions/56-the-netherlands

ETHRA submission for the NL regulation of e-cigarette flavours consultation.

Thank you for the opportunity to comment on this consultation. Our contribution outlines why restricting e-liquid flavours will be detrimental to Dutch public health.

European Tobacco Harm Reduction Advocates (ETHRA) is a group of 22 consumer associations in 16 European countries, representing approximately 27 millionⁱ consumers across Europe 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.

The stated rationale for the proposed flavour restrictions is to achieve a smoke-free generation by 2040, and to provide a public health benefit. We believe that the proposal is counterproductive to that aim. Severely limiting the products which people use to remain smoke-free will only prolong smoking and have a negative effect on public health.

Vaping is proven to help people quit smoking and remain smoke-free

As ex-smokers we are painfully aware of how difficult it can be to quit smoking and many of us could only quit using vaping products after other methods had failed us. Vaping is indeed a popular and effective method of quitting smoking for adults and this is borne out by data from Belgium, France, Ireland, and the UKⁱⁱ. Evidence from randomised control trials (RCT) also support the efficacy of vaping for smoking cessation. A large scale RCT by Hajek et al found vaping to be almost twice as effective as nicotine replacement therapyⁱⁱⁱ. An ongoing Cochrane review and meta-analysis finds that vaping is 67% more effective than NRT’si^v.

Switching from smoking to vaping is beneficial to health

Switching from smoking to vaping has been shown to provide significant benefits for respiratory and cardiovascular health.

The primary cause of harm from smoking is combustion. As vaping does not involve combustion the relative risk is vastly lower than smoking. Discussing the relative risks of vaping compared to smoking, the UK Royal College of Physicians stated in its 2016 report Nicotine Without Smoke^v 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.” Public Health England stated in its 2018 evidence review that the cancer potencies of e-cigarettes were largely under 0.5% of the risk of smoking^vi.

Expert opinion^vii from an assessment of published research on the respiratory system and e-cigarettes stated: “growing evidence supports the relative safety of EC emission aerosols for the respiratory tract compared to tobacco smoke.” A RCT published in the Journal of the American College of Cardiology found significant improvements in cardiovascular health within one month of switching from smoking to vaping^viii.

The Decree for regulating e-cigarette flavours raises concern of dual use, however quitting smoking can be a long process and it is very common for smokers to dual use when they first start vaping but to then quit smoking entirely.

A wide variety of flavours is crucial for winning over smokers

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^ix. Disassociation with the taste of tobacco, as well as enjoyment of the product being used, are very important factors for adult smokers to avoid relapse to smoking.

An analysis of the Dutch e-cigarette market by Havermans et al^x also highlighted the importance of non-tobacco flavours for Dutch smokers. The researchers concluded that “adults who completely substituted the use of conventional cigarettes by e-cigarettes have often initiated e-cigarette use with fruity flavours rather than tobacco flavours, or switched from tobacco to non-tobacco e-liquid flavours over time.”

A recent study published in JAMA^xi concludes that “adults who began vaping non-tobacco flavored e-cigarettes were more likely to quit smoking than those who vaped tobacco flavors.”

Research by RIVM^xii 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.”

It must also be noted that nicotine gums come in a range of flavours, an important characteristic in their efficacy. A German study^xiii from 2011 stated “Product characteristics of nicotine gums, such as crunchiness, sweetness and flavour, appear to be crucial for the expectations that smokers have in the likelihood that any particular nicotine gum will help them to quit smoking.”

The explanatory memorandum states that e-cigarettes are mainly used by adults who smoke, have smoked and/or want to quit smoking. 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.

Vape flavour bans create black markets

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 (or go back to smoking). 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^xiv. In response, Estonia recently amended its flavour legislation.

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, or become, free from cigarette smoking.

Vape flavour bans increase smoking

A study^xvi 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%.

Banning flavours can increase health risks

The dangers of inhaling oil-based solutions are highlighted in section 2.2 ( Harmfulness of e-cigarettes) of the exploratory memorandum, albeit in a highly misleading way. EVALI was caused by vitamin E acetate used in illicit THC products^xvii. However, this compound was never, and could never be used in nicotine e-liquid. E-liquid is a water-soluble solution (hydrophilic), vitamin E acetate is non-water soluble (hydrophobic) used in oil-based solutions. Added to that, vitamin E acetate is already a banned substance under the TPD.

Equally misleading is the inclusion of Diacetyl in the exploratory memorandum, with reference to a risk of bronchiolitis obliterans (popcorn lung) from vaping. Bronchiolitis obliterans is an extremely rare disease that was found only in a group of popcorn factory workers. Cancer Research UK^xviii had this to say “There’s no good evidence that e-cigarettes could cause the lung condition called popcorn lung. There’s been no confirmed cases of popcorn lung reported in people who use e-cigarettes.” Diacetyl is also a banned substance under the TPD.

Use of vapour products among never smoking youth is rare and does not lead to nicotine dependence

The exploratory memorandum discusses youth use of e-cigarettes in the USA, described as an ‘epidemic’. However, an examination of the National Youth Tobacco Survey 2019^xix found that frequent use of e-cigarettes among tobacco naïve young people was rare. A further study of National Youth Tobacco Survey data concluded that vaping was a diversion away from smoking^xx. Youth smoking in the USA is at historically low levels and continuing to fall.

A recently published study^xxi on nicotine use by young people in the USA concluded that “Among US high school students, increases in the prevalence of nicotine product use from 2012 to 2019 do not appear to have been accompanied by a similar increase in the population burden of nicotine dependence. This may be at least partly attributable to a shift in the most common product of choice from cigarettes (on which users are most dependent) to e-cigarettes (on which users are least dependent).”

In the Netherland, Jongeren en riskant gedrag^xxii from TRIMBOS shows that 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 regard to youth smoking and youth vaping, as prevalence is low and moving downwards for both.

Dutch adult smokers the collateral damage

We are surprised and concerned to see that the rationale given for the restriction of flavours is that it will provide a public health benefit by discouraging the use of e-cigarettes. These measures will in fact have the opposite effect by negatively impacting adult smokers the most. Adult smoking prevalence in the Netherlands is high, at 21.7%^xxiii. This 21.7% represents a lot of people who could benefit greatly from switching to a less harmful product.

The cost of smoking is not only felt in terms of health, but also economically. Smoking is very expensive and smoking prevalence is highest in the more disadvantaged socioeconomic groups. Vaping is cheaper than smoking and so offers smokers an alternative which is not only less harmful but also less expensive. Making vaping less attractive to smokers by limiting flavours will keep more people smoking, and spending money on cigarettes.

Conclusions

Vaping is far less risky to health than smoking. Making these products less attractive to adult smokers and restricting their availability will have a negative effect on public health by perpetuating smoking. The Royal College of Physicians has warned of the unintended consequences of overregulating vaping products^xxiv

“if a risk-averse 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.”

(section 12.10 page 187)

We share your commitment to health prevention and promotion but banning flavours will not serve that purpose.

ETHRA is listed in the EU Transparency Register at: 354946837243-73.

References

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. Interview on Tobacco Products Directive: notes by ETHRA, pps 8-9 Impact of e-cigarettes on smoking cessation. Available at: https://ethra.co/images/ETHRAs_notes_on_TPD_interview.pdf
Hajek, P. et al. (2019) ‘A randomized trial of E-cigarettes versus nicotine-replacement therapy’, New England Journal of Medicine, 380(7), pp. 629–637. doi: 10.1056/NEJMoa1808779.
Hartmann-Boyce, J. et al. (2020) ‘Electronic cigarettes for smoking cessation’, Cochrane Database of Systematic Reviews, (10). doi: 10.1002/14651858.CD010216.pub4.
Royal College of Physicians (London), Nicotine without smoke: tobacco harm reduction, April 2016
McNeill, A. et al. (2018) ‘E-cigarettes and heated tobacco products: evidence review Annual update of Public Health England’s e-cigarette evidence review by leading independent tobacco experts.’, Public Health England, pp. 1–243. Available at: https://www.gov.uk/government/publications/e-cigarettes-and-heated-tobacco-products-evidence-review.
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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
A. Havermans, E.J.Z. Krüsemann, J. Pennings, et al. ‘20 000 e-liquids and 250 unique flavor descriptions: an overview of the Dutch market based on information from manufacturers’, Tobacco Control 2019.
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ETHRA submission for the NL regulation of e-cigarette flavours consultation.

January 2021. ETHRA submitted to the Netherland Ministry of Health, Wellbeing and Sports public regulation of e-cigarette flavours consultation.

You can download our submission here (PDF)