Contribution to the Dutch Consultation on Restriction of Flavours

IEVA today submitted a contribution to the Dutch consultation on Restriction of Flavors.

Here is the text:

More than 29.000 deaths in the Netherlands per year are related to smoking. [1] For those smokers who do not succeed in quitting with traditional nicotine replacement therapy, switching to e-cigarettes reduces smoking related health risk exposure by 95%. [2] As the Independent European Vape Alliance (IEVA), the pan-European association of the vaping sector, we support tobacco harm reduction for adult smokers. Hence, we would like to use the opportunity to stress the potential negative consequences of a flavour-ban and outline positive international examples successfully integrating vaping in a harm reduction approach for the benefit of public health.

Recent analysis provide the following overview on smoking, vaping and youth consumption:

99,8% of all Dutch users of e-cigarettes come from smoking. [3]
Despite a growing recognition of e-cigarettes, the number of underaged tobacco smokers declined by 25% from 2015. [4]
During the past 5 years the number of youths who ever tried e-cigarettes decreased by 25%. [5]
Flavours other than tobacco are a significant factor of success for smokers in their attempts to quit smoking. [6]
A study carried out in 8 EU member countries, shows that The Netherlands have the best long-term quitting success rates for smokers using e-cigarettes. [7]
A survey by the Yale School of Public health based on more than 17,000 respondents aged from 12 to 54 years old concluded that “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”. E-liquids with flavours other than tobacco are not a gateway to youth uptake of smoking. No evidence substantiates the association between vaping flavours and subsequent smoking initiation. [8]

E-Cigarettes are an internationally recognized aid to stop smoking
According to the DEBRA study conducted by the University of Düsseldorf and funded by the German Federal Ministry of Health, e-cigarettes are the most commonly used tobacco cessation method in Germany. Further, Great Britain and New Zealand successfully incorporate vaping in their public health strategies.

Following a randomized study trial published in the New England Journal of Medicine 2019, e-cigarettes are almost twice as successful as a stop-smoking aid measured by a 1-year abstinence rate of 18% with e-cigarettes to 9.9% with nicotine-replacement products – both aids were accompanied by weekly behavioural coaching. Furthermore, the systematic landmark report by the international Cochrane Database concludes e-cigarettes to be 70% more effective in helping smokers quit than nicotine replacement therapy: “For every 100 people using nicotine e‐cigarettes to stop smoking, 10 might successfully stop, compared with only six of 100 people using nicotine‐replacement therapy or nicotine‐free e‐cigarettes, or four of 100 people having no support or behavioural support only.” [10]

Vaping as part of national public health strategies: Regular vaping among minors is confined to smokers
Action on Smoking and Health NZ (2020) shows in a survey among 30.000 minors that over 99% of the 3.1% under-aged regular vapers are actual tobacco smokers. “Our findings are consistent with other national surveys and do not support the idea of a so-called youth vaping epidemic […] we believe that e-cigarettes might be displacing smoking for young people. Concerns about youth vaping should be weighed against the possibility that e-cigarettes could decrease the risk of smoking initiation and support smoking youth to quit.” [11]

Further, an analysis of several UK studies by Public Health England with over 60,000 minors shows: “young people are experimenting with e-cigarettes, but regular use is rare [<3.0%] and confined almost entirely to those who already smoke [> 99.5%]. Meanwhile, smoking rates among young people in the UK continue to decline.” [12]

National public health authorities integrate vaping as a means to quit smoking in a harm reduction approach. Together with anti-tobacco NGOs they educate smokers about vaping in nationwide anti-tobacco campaigns and online services. [13] Following this approach, the UK has Europe’s second smallest smoking rate, while New Zealand strives promisingly for a smoke free nation in 2025. [14]

No link to EVALI in the U.S.
The EVALI crisis in 2019 in the U.S. is not related to e-cigarette or e-cigarette e-liquids. As illegal THC-containing liquids for e-joints are the proven cause of the significant health incidents in 2019 in North America, the U.S. Centers for Disease Control and Prevention (CDC) lifted the warning against conventional e-cigarettes on Jan. 17, 2020. The toxins contained in the substances for e-joints are banned in the European Union. Yet the rather fragmentary U.S. regulation is not comparable to the comprehensive legislation in Europe. Andreas Hensel, President of the German Federal Institute for Risk Assessment (BfR) publically explained in German news magazine Stern that “consumers of e-cigarettes in Germany do not face any increased risks, provided they use products that comply with European and German regulations”. [15]

Vaping offers harm reduction for adult smokers
E-cigarettes offer adult smokers an alternative which is significantly less harmful than smoking as emphasized by regulators such as the French Economic, Social and Environmental Council (CESE) [16] , the National Institute for Public Health and the Environment in the Netherlands (RIVM) [17], Public Health England [18] and the Royal College of Physicians [19]. Public Health England concluded in a landmark review of the available evidence, that e-cigarettes represent at least 95% harm reduction versus conventional cigarettes.

In sum:

The number of youth smoking or trying e-cigarettes is in stable decline, despite the growing recognition of e-cigarettes
Youths who vape are not motivated by flavours
E-cigarettes help a group of smokers successfully quit which is almost twice as big as the group of smokers who tries with conventional nicotine replacement therapy
Nations who supportively include e-cigarettes in their public health strategy show significantly low smoking rates
EVALI was not caused by e-cigarettes or e-liquids but by substances designed for e-joints, which are banned in EU

IEVA respectfully calls on the Ministry of Health, Welfare and Sport to closely consider the aforementioned data and international examples.

IEVA contribution (PDF):

Sources:[1] Tobacco Atlas on Netherlands, 2018[2] Public Health England, 2018: Evidence review of e-cigarettes and heated tobacco products[3] Trimbos Instituut, 2019: Cijfers roken; Rijksinstituut voor Volksgezondheid en Milieu, last up-dated 2020: Leefstijlmonitor[4] NL Statline Dataset[5] Trimbos Instituut, 2020: Factsheet Elektronische Sigaretten[6] Sundhedsstyrelsen, 2020: The Danes’ smoking habits in 2019, p. 20; WHO, 2020: Electronic nicotine and non-nicotine delivery systems: a brief[7] Hummel, K. et al., 2018: Quitting activity and use of cessation assistance reported by smokers in eight European countries: Findings from the EUREST-PLUS ITC Europe Surveys[8] Friedman, A.S. and X. SiQuin, 2020: Associations of Flavored e-Cigarette Uptake With Subsequent Smoking Initiation and Cessation [9] Kotz, D. et al., Deutsches Ärzteblatt, 2018 doi:10.3238 /arztebl.2018.0235; Public Health England, last up-dated 2020: E-cigarettes and vaping: policy, regulation and guidance; Ministry of Health New Zealand, 2020: Smokefree Environments and Regulated Products (Vaping) Amendment Act[10] Action on smoking and Health, 2020: E-cigarette use decreases as evidence shows they increase smokers’ chances of quitting and Cochrane Library, 2020: Electronic cigarettes for smoking cessation[11] Campaign of New Zealand’s Ministry of Health (MoH), 2020: vapingfacts.health.nz; Federal Info-Website „Quitline“, 2020: quit.org.nz; MoH: Regulatory Impact Statement: Regulation of e-cigarettes. Nov. 2017, p. v; Smokers’-Statistics MoH NZ, 2019: Smoking is a dying habit; minhealthnz; ASH NZ, 2020: E-Cigarettes displacing youth smoking; ASH UK, 2019: Using e-cigarettes to stop smoking[12] Public Health England (PHE), last updated 2020: Stoptober-Campaign; National Health Service: E-cigarettes, nhs.uk; PHE 2018: Evidence review of e-cigarettes and heated tobacco products; PHE, 2020: Vaping in England; PHE, 2020: 8 things to know about e-cigarettes; ASH Pressrelease, 18.06.2019: In Britain young people vape just to give it a try, not because they think it’s “cool”; Cancer Research UK: E-cigarette Hub; Bauld et al., 2017: Young People’s Use of E-Cigarettes across the United Kingdom: Findings from Five Surveys 2015–2017[13] NZ MoH Vaping educational online offers, 2019: https://vapingfacts.health.nz/ and National Health Service UK, 2019: Using e-cigarettes to stop smoking[14] Federal Center of Health Education Germany (BZgA): Tabakkonsum in Europa https://www.rauchfrei-info.de/informieren/verbreitung-des-rauchens/raucherquote-in-europa/; New Zealand MoH https://www.smokefree.org.nz/smokefree-in-action/smokefree-aotearoa-2025[15] US Center of Disease Control, 2020: Severe Lung Disease; The Wall Street Journal, 2020: DC Steps Back From Broad Recommendation to Refrain From E-Cigarettes; Stern.de, 2019: Nach Todesfällen in USA: Deutscher E-Zigaretten-Umsatz bricht ein[16] French Economic, Social and Environmental Council, 2019: Les addictions au tabac et à l’alcool[17] RIVM Netherlands, 2015: The health risks of using e-cigarettes[18] Public Health England, last up-dated 2020: E-cigarettes and vaping: policy, regulation and guidance[19] Royal College of Physicians, 2016: Promote e-cigarettes widely as substitute for smoking says new RCP report