Letter to the Dutch Parliament to express concern about the possible ban on flavoured e-cigarettes in the Netherlands
- Monday, 19 October 2020 23:41
While everyone's attention is essentially on the COVID-19 pandemic, there are some developments in the field of tobacco harm reduction and e-cigarettes. Besides the recent SCHEER report, for which i will prepare a detailed response, another important issue has been the discussions in the Netherlands concerning a potential ban on flavored e-cigarettes. Together with Dr Karolien Adriaens and Prof Fran Baeyens from the Univ. Of Leuven, we prepared a letter that was sent to the Secretary for Health, Welfare and Sports concerning this issue. The leter is presented below.
Parliament of the Kingdom of the Netherlands
Secretary for Health, Welfare and Sports
For the attention of: Mr Paul Blokhuis
cc, Standing Committee on Public Health, Welfare & Sports
11 September 2020
Letter from International Experts and Academics in Tobacco Control to express concern about the possible ban on Flavoured E-Cigarettes (ENDS) in the Netherlands
Honourable Mr. Blokhuis,
We are scientists with an established work and publication record in the field of smoking and tobacco harm reduction. Based on our research and on the assessment of the totality of evidence we support the strong potential of tobacco harm reduction to significantly contribute to the elimination of smoking. With this letter we kindly present our views in relation to discussions about a possible ban on flavoured e-cigarettes and other restrictions that the authorities might be considering.
In a previous letter to the Dutch Parliament on March 4 2019, signed by 36 international experts, we welcomed the initiative to strengthen the regulatory framework in order to further reduce smoking prevalence, but we urged the government to carefully consider the totality of evidence concerning e-cigarettes and to examine the possibility that they are part of the solution in the smoking problem. E-cigarettes currently appear to be the method of choice for smokers to quit, and can play a significant role in preventing tobacco-related disease and premature death. This product category can literally save lives.
Therefore it has been most concerning to hear that the Dutch Government is considering a ban on flavoured ENDS, ironically only retaining tobacco-flavoured ENDS.
We respectfully write to you in view of the upcoming discussion in the Dutch Lower House about the National Prevention Agreement. We very much welcome the objectives and existing tobacco control measures set out in the Agreement which are in line with the WHO Framework Convention on Tobacco Control. Any policy intervention that reduces smoking in the Netherlands has our full support.
We do regret however, that the Agreement fails to acknowledge the important role that flavoured ENDS is playing in reducing the harms caused by smoking. From a health perspective, the major distinction between nicotine products is based on the presence or absence of combustion. It is well known that it is smoke, not nicotine, which causes almost all of the smoking related diseases. Non-combustible products have a clear role to play in reducing smoking prevalence to meet the ambitious objectives set out in the Agreement.
On the subject of smoking cessation, there is increasing evidence from Randomised Controlled Trials (RCTs), designed specifically to explore effects on tobacco smoking, that vaping products (e-cigarettes) can help smokers quit. A Cochrane review published in 2016  concluded that smokers using an e-cigarette were more likely to quit compared to those using a placebo at 6 months. More recently, a RCT of e-cigarettes versus Nicotine Replacement Therapy (NRT) alongside behavioural support in England, reported an almost two-fold increase in 12 month quit rates with e-cigarettes .
A survey conducted in 4618 participants showed that adult e-cigarette users (most of whom were former smokers) were using a variety of different, non-tobacco, flavours . In another study of > 60.000 adult vapers (again most of them were former smokers), the vast majority eventually transitioned to fruit, dessert or candy flavours that do not resemble and did not remind them of the taste and experience of tobacco cigarettes . This clearly indicates that flavours are marketed in order to satisfy adult vapers' demand. They appear to contribute to both perceived pleasure and the effort to reduce cigarette consumption or quit smoking. Therefore, implementing regulatory restrictions to flavours could cause harm to current adult vapers. Eliminating the flavours in ENDS or applying other restrictions that reduce the attractiveness of e-cigarettes for smokers will defeat their public health purpose, aims and gains already made in smoking cessation.
Moreover, policies restricting access to flavours are unlikely to achieve their stated goals, and are likely to have unintended consequences. A “flavour ban” may actually increase teen harms. There is broad agreement that no one wants under-age persons to vape. Concerns have been raised from data in the US that teen e-cigarette use has increased over the years. However, most use is infrequent, experimental and largely confined to teens with a smoking history . Furthermore, the increase in experimental e-cigarette use has coincided with the largest reduction in teen smoking rates, which are now at historically low levels. Flavours are only the third most prevalent reason for e-cigarette use among US teens. But even if a flavour ban does marginally reduce the illegal behaviour, we need to ask – how many adult lives are we willing to put at risk, and how many smokers will miss the opportunity to reduce their health risks in order to achieve that goal? A recent study found that non-tobacco flavours was no more associated with youth smoking initiation than using tobacco flavours but was associated with increased adult smoking cessation . Additionally, a flavour ban would not prevent teens who want to engage into such a behaviour from seeking other legal sources of flavours, such as products used by the food industry. This will in fact create an uncontrolled market in terms of product quality and regulation. Other studies have reported that restrictions in e-cigarette availability might even promote smoking [7,8]. Ultimately, there is insufficient evidence that an ENDS flavour ban will reduce underage vaping, but there is evidence that such bans might not achieve that goal and could harm adult smokers. The European Union has an established regulatory framework on e-cigarettes which includes a ban on the sales to youth. The best approach that would prevent unintended consequences is undoubtedly the strong implementation and enforcement of the current regulation concerning the sales ban to youth.
In addition, as is the case across the globe, in the Netherlands there are many smokers that are unable or unwilling to quit, not least of all the poorest and most disadvantaged in society who find smoking cessation the most difficult. This large group, including those suffering from mental illness, would benefit from switching to smoke-free products. In this regard it is critical that adult smokers can be informed about these innovative products and receive balanced, reliable and accurate information about their relative risk. However subjecting e-cigarettes and other smoke-free products to the same restrictions as for combustible cigarettes can have unintended consequences. It is practically misinforming smokers about the relative risks of e-cigarettes compared to tobacco cigarettes, discourages them from making the switch, and will eventually favour the tobacco industry. How is this possible? As articulated by the Royal College of Physicians : “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.” (Section 12.10 page 187). A horizontal implementation of similar restrictions on e-cigarettes as for tobacco cigarettes also defies the risk proportionality principle, a fundamental approach in preparing public health regulatory frameworks, and is contradictory to the overwhelming evidence on the lower harm potential of e-cigarettes compared to smoking. Such a proposal is likely to result in net public health harm and will definitely harm the smoking population.
Finally, may we reiterate that whilst we welcome tighter restrictions on cigarette smoking, banning flavoured e-cigarettes will discourage smokers from switching, which leads to the unintended consequence of continuous and prolonged smoking. Instead, the authorities should focus on successfully enforcing the current regulatory framework which includes a ban on the sales of these products to youth.
We respectfully ask the Lower House to carefully assess the role of flavours in non-combustible products such as e-cigarettes, specifically in reducing smoking prevalence and preventing tobacco-related disease and death. We would welcome the opportunity to contribute to any consultation by your Committee, should you decide to organize such type of event.
We report no conflicts with respect to FCTC Article 5.3 and no financial conflicts of interest with respect to tobacco or e-cigarette companies under the International Committee of Medical Journal Editors (ICJME) reporting standard.
Signatories (in alphabetical order)
Karolien Adriaens, PhD
Faculty of Psychology and Educational Sciences
KU Leuven, Belgium
Frank Baeyens, PhD
Faculty of Psychology and Educational Sciences
KU Leuven, Belgium
Konstantinos Farsalinos, MD, MPH
University of Patras, Greece
School of Public Health, University of West Attica, Greece
3. Farsalinos K, Romagna G, Tsiapras D, Kyrzopoulos, Spyrou A, Voudris V, Int J Environ Rs Public Health, 2013 Dec. https://pubmed.ncbi.nlm.nih.gov/24351746/.
4. Farsalinos K. et al. Patterns of flavored e-cigarette use among adult vapers in the United States: an internet survey. https://www.regulations.gov/document?D=FDA-2017-N-6565-22941.
5. Farsalinos K, Barbouni A, Niaura R. Changes from 2017 to 2018 in e-cigarette use and in ever marijuana use with e-cigarettes among US adolescents: analysis of the National Youth Tobacco Survey. Addiction. 2020 Jun 13. doi: 10.1111/add.15162. https://pubmed.ncbi.nlm.nih.gov/32533631/.
6. Friedman AS, Xu S. Associations of Flavored e-Cigarette Uptake With Subsequent Smoking Initiation and Cessation. JAMA Netw Open. 2020 Jun 1;3(6):e203826. doi: 10.1001/jamanetworkopen.2020.3826. https://pubmed.ncbi.nlm.nih.gov/32501490/.
7. Friedman AS. How does electronic cigarette access affect adolescent smoking? J Health Econ. 2015;44:300–8. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0167629615001150.
8. Pesko MF, Hughes JM, Faisal FS. The influence of electronic cigarette age purchasing restrictions on adolescent tobacco and marijuana use. Prev Med (Baltim). 2016;87:207–212. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0091743516000396.
On behalf of all signatories,
Konstantinos Farsalinos, MD, MPH