January 27th, 2021

Will the Netherlands become the next casually negligent ally of the cigarette trade? Twenty-four experts advise a rethink

So let’s make the e-cigs less appealing and see what happens… what could possibly go wrong?

The Netherlands is proposing to ban e-cigarette flavours – what could possibly go wrong?

The government of the Netherlands,  led by Paul Blokhuis, State Secretary for Health, Welfare and Sport, is in imminent danger of fooling itself into becoming an unwitting ally of the cigarette trade.  By taking measures to make vaping less attractive (notably by proposing a ban on all non-tobacco flavours for e-cigarettes), it threatens to degrade the appeal of a low-risk rival to cigarettes, provide regulatory protection to the cigarette trade, prolong smoking, obstruct quitting, and add to the burden of disease and death. All this in the name of protecting youth, while managing to harm both adults and adolescents. Quite a feat for any politician.

The problem is hubris – believing that the world responds to regulation in the way the regulator thinks it should. Experience suggests foreseeable perverse consequences will be the result of the ill-conceived prohibitions of much safer alternatives to smoking, including flavoured e-cigarettes.

It really isn’t difficult to understand why and how this would happen – I can only assume the State Secretary received very poor advice, which would not be unusual in this field.  Nevertheless, twenty-four international experts have set out the arguments and evidence in detail in a submission to the Dutch government, hoping to spare Mr Blokhuis later embarrassment and, even more importantly, to avoid yet more death and disease from smoking in the Netherlands.  It should also be a wake-up call to like-minded politicians and naive policymakers in the United States, European Union, and the World Health Organisation who continue to fail to grasp the impact of low-risk products in the real world.

The case is set out in 30-page submission to a Dutch government consultation on the measure.  The relevant documents are:

To provide a more digestible version of the submission, I have included below the twelve sections of the summary below with a link to the corresponding twelve sections with more detail and references.

Summary and links to detail

The case for the ban on vaping flavours described in the memorandum supporting the measure is wholly inadequate, and the measure should not proceed on this basis.  The critical weaknesses in the rationale described in the memorandum are as follows:

  1. Sets conflicting objectives and takes a “war on drugs” approach to nicotine. The proposed measure is supposed to support a “smoke-free Netherlands” objective for 2040 as part of the Prevention Agreement. As stated, this is a sensible goal and should be widely supported – it recognises that smoke, not nicotine, is the overwhelming cause of disease. It is practical and achievable if smoke-free alternatives to smoking, such as vaping products, are available. However, the proposal introduces a significant expansion of scope by extending “smoke-free” to mean all tobacco, even if not smoked and then to tobacco-free nicotine products like e-cigarettes. It will make it impossible to use harm-reduction approaches, despite the enormous potential to reduce disease and death.  It misunderstands the nature of youth risk behaviours. It amounts to extending the war on drugs to nicotine, but at a time when failures of prohibition are widely recognised. It would be better to stick to a smoke-free goal and use smoke-free alternatives to achieve it rather than pursue nicotine prohibition. The Netherlands is rightly world-famous for its pragmatic approach to soft drugs — that pragmatism should be leveraged to accelerate the end of smoking in the Netherlands by embracing harm reduction for those who smoke.
    [More detail]
  2. Adopts false and misleading claims about the risks of e-cigarettes. The justification fails to adequately characterise the overwhelming evidence showing e-cigarette use is much less harmful than smoking. Suppose policymakers believe e-cigarettes are just as harmful as cigarettes. In that case, their policies will be detrimental to public health by hindering substitution as smokers move from high-risk to low-risk products. It is clear from toxicology and exposure studies that e-cigarettes are, beyond any reasonable doubt, far less harmful than cigarettes. It is simplistic to apply the precautionary principle to use long-term uncertainties to justify excessive regulation. This ignores the substantial body of science suggesting much lower risk and neglects the problem that excessive regulation can cause harm by protecting the cigarette trade, which is known to be highly harmful.
    [More detail]
  3. Draws on irrelevant information about an outbreak of lung injuries in North America. Without a credible case for harm arising from e-cigarette use, the justification includes distracting and irrelevant references to “EVALI”, an outbreak of severe lung injuries in the United States in 2019. EVALI was caused by the addition of a cutting agent, Vitamin E Acetate, to illicit cannabinoid (THC) vape pens. This substance cannot be added to nicotine liquids and would serve no purpose if it could.  There is no other credible evidence of material risks of severe lung injury.
    [More detail]
  4. Misunderstands “dual-use”. Concurrent use of e-cigarettes and cigarettes (“dual-use”) should be understood as progress towards reducing smoking or smoking abstinence in most cases. Unless a smoking cessation method is 100% and immediately effective, it will mean some continued smoking on the pathway to smokefree status whatever method is used.  It is true that some ‘dual users’ do not see significant reductions in toxicant exposure, but that is likely caused by higher dependence for which dual use is a marker. It is likely that public hostility to e-cigarettes, including from the government, agencies and academics, contributes to users not appreciating the benefits of switching completely. A cause of dual-use-related harm could, in part, be negative statements of tobacco control activists, academics and politicians.
    [More detail]
  5. Asserts a “gateway effect” but there is more likely to be a diversion away from smoking. The memorandum claims there is a gateway effect from vaping to smoking. At an individual level, some adolescents will be likely to take up e-cigarette use, but there is also growing evidence that other adolescents who would otherwise have smoked are diverted away from starting to smoke. This diversionary effect is consistent with observed declines in youth smoking prevalence despite the recent increases in e-cigarette use as the technology has emerged. The strong correlations between smoking and vaping commonly reported in the literature are likely partly caused by ‘common liabilities’.  These are characteristics such as genetics, mental health status, home environment, community, school etc. that incline a young person both to smoking and to vaping. The vaping cannot be assumed to cause the smoking. Regulating based on assumptions of a gateway effect where none exists is not responsible or ‘precautionary’. Over-regulation of e-cigarettes, the far safer product, could prevent e-cigarettes functioning as a diversion from smoking for young people.
    [More detail]
  6. Takes a simplistic approach to youth risk behaviours and fails to demonstrate benefits to adolescent public health. The rationale offered is grounded in a naïve account of youth risk behaviours, which do not stop simply because adults in authority disapprove of them or pass laws to prevent them. There is a long and complicated chain of causation from a ban on e-cigarette flavours to improved health, with many possible diversions into perverse and harmful consequences. Legislating to ban something does not make it go away or necessarily cause its existing users to become abstinent – it provokes a variety of responses on the part of consumers. Illicit drugs are subject to prohibitions and strong sanctions yet are still widely used and supplied by criminal enterprise.  The proposal lacks justification of the measure as a successful youth-orientated public health intervention.  Without realistic insights into youth risk behaviours, the government is likely to regulate in a way that increases harm to young people – for example, by tacitly encouraging young people to revert to smoking.
    [More detail]
  7. Ignores perverse consequences of prohibition, even though these are foreseeable. The case provides little analysis of a range of harmful perverse consequences that could arise from a prohibition of vaping flavours. These are foreseeable, yet not foreseen in the justification as presented.  They include but are not limited to:
    • Fewer smokers switching to vaping
    • More vapers relapsing to smoking
    • Teenagers smoking instead of vaping
    • More teenagers switching to vaping cannabinoids such as THC
    • Cross-border sales of flavoured e-liquids
    • More home mixing of flavoured liquids (with additional risks)
    • Black market trade in flavoured liquids and flavoured e-cigarettes
    • Workarounds like selling flavours separately or use of food flavours
    • Loss of legitimate retail and online businesses replaced by criminal networks or exporters from outside the Netherlands or European Union.

[More detail]:

  1. Fails to show benefits for adolescents or address concerns it may cause harm to young people. The justification fails to articulate the benefit for youth. It does not show that:
    • Flavours play an important causal role in adolescent vaping
    • A ban on flavours would reduce adolescent vaping, rather than just stimulate workarounds
    • If reductions in adolescent vaping were achieved as intended, this would translate to a benefit to health and not trigger an uptick in other risk behaviours.

[More detail]

  1. Ignores the harmful effects of a vaping flavour ban on adults. Where vaping displaces smoking – both in adults and adolescents – there are health, welfare, and economic gains for the users and for society. These benefits have been largely ignored in the reasoning presented to support the ban.  The government’s own target is to be smoke-free by 2040 – the substitution of smoke-free alternatives in place of cigarettes will be critical in meeting that target.
    [More detail]
  2. Creates regulatory protection for the cigarette trade. The case does not recognise that vaping is an alternative to smoking and a pathway for smoking cessation and that flavours are an important part of the experience for adults. In obstructing this pathway and making it practically harder and less attractive for smokers to switch or risking that vapers will relapse to smoking, the proposals amount to a regulatory defence of the cigarette trade. While this is unlikely to be the government’s intention, it may well be the perverse effect of this proposed intervention.  It is quite possible that the e-cigarette flavour ban will protect the cigarette trade and increase smoking, resulting in more disease and death. Nothing in the memorandum provides an adequate counter to these concerns. The government should adopt “risk-proportionate regulation”, which encourages producers and consumers to migrate from high-risk to low-risk products — rather than unjustified regulation that will inhibit switching away from smoking.
    [More detail]
  3. Violates important regulatory principles, including those underpinning the European Union internal market. The proposed measure is disproportionate, discriminatory, anti-competitive, and counter to the aims of the European Union internal market. A key competitive advantage of e-cigarettes over cigarettes is the availability of diverse flavours (other than tobacco flavour). The availability is important because most adult users prefer these non-tobacco flavours. The proposed measure is indiscriminate in banning all but one flavour and does not adequately show that all non-tobacco flavours or descriptors have particular appeal to youth.
    [More detail]
  4. Proposes an illiberal policy and fails to recognise a major global public health opportunity. Though it is a political judgment, the measure appears to be excessively illiberal in its intrusion in adults’ rights to protect their own health, on their own initiative, and at their own expense – or simply to use nicotine in a much safer way, if they choose to. It sets a precedent for governments to use potential risks to youth to curtail reasonable adult free choices. The aim should be to use targeted measures to control youth risks, not general measures that target all users. The policy overreacts to relatively minor and manageable risks but denies or ignores a significant opportunity to help millions of smokers radically reduce their health risks. In its role as Chair of the WHO Framework Convention on Tobacco Control Conference of the Parties in 2021, the Netherlands should be leading a positive approach to tobacco harm reduction.
    [More detail]

Twenty four signatures

Full affiliations here.

  1. David B Abrams, PhD
  2. Karolien Adriaens, PhD
  3. Clive Bates, MSc, MA
  4. Frank Baeyens, PhD
  5. Ron Borland PhD FASSA
  6. Sharon Cox PhD
  7. Lynne Dawkins, PhD
  8. Jean-François Etter, PhD
  9. Konstantinos Farsalinos, MD, MPH
  10. Peter Hajek, PhD
  11. Martin J Jarvis, DSc OBE
  12. Lynn T. Kozlowski, Ph.D.
  13. Eva Kralikova, MD
  14. Christopher E. Lalonde, PhD
  15. Jacques Le Houezec, PhD
  16. Karl Erik Lund PhD
  17. Bernd Mayer, PhD
  18. Raymond S. Niaura, PhD
  19. Caitlin Notley, PhD
  20. Lars M. Ramström, PhD
  21. Lion Shahab, PhD
  22. Andrzej Sobczak, PhD
  23. David T. Sweanor J.D.
  24. Professor Umberto Tirelli MD

My take on Twitter

While reading the case for the measure

Twitter thread for this blog

 

image_pdfPrintable/PDF version

15 comments to Will the Netherlands become the next casually negligent ally of the cigarette trade? Twenty-four experts advise a rethink

  • Declan Connolly

    Great blog post Clive. Summarises the argument against a flavour ban really well. Might be using same argument here in Ireland, as here too there is mention of flavour bans.
    Declan

  • Roberto Sussman

    Flavor bans must be seen also from other angles besides its impact in smoking cessation: it is a deliberate attempt to “uglify” the product (e-cigarette). The message is not only to dissuade users (actual and potential), but to spread to the general society an image of an ugly product, so that those using it (or potentially interested in using it) are cast in negative light to the broad population, after shouldn’t there be something wrong with somebody attracted to an ugly product?

    Flavor bans must also be embedded into how anti-THR actors aim at equating THR products with combustible products, something which involves equating policies to regulate or ban them. The historic pattern in cigarettes policies shows an evolution to gradually increasing levels of restriction. Since for the anti-THR crowd vaping = smoking, then policies towards vaping must evolve as those towards smoking (with a time lapse because vaping emerged much later).

    The practical effect of this “treat vaping like smoking” is a time scale for gradual hardening of policies. Now in Holland, the USA and other countries their goal is just to ban flavors, tomorrow after the public got used to this ban it will be to ban open systems, after tomorrow, probably to ban all non-pharmaceutic devices, next, to ban all nicotine from the planet (why not? after all this technocracy has never been subjected to scrutiny).

    As much as the utility of vaping for smoking cessation is important, flavor bans have to be opposed (in my opinion) also because they are an extremely authoritarian attempt to debase a product and stigmatize all actual and potential users who enjoy consuming it. Would people have a beer if the bottle is gluey and ugly and the taste is like medicinal piss? Can the sponsoring of this be justified as a necessary move to combat alcoholism among youth? Would it be a correct strategy to oppose such policy simply by saying that it would fail to combat alcoholism? These arguments can be generalized to most consumer items, for example lots of high caloric and sugary food and drinks vs obesity and diabetes.

    • I think the point about ‘uglification’ is really important – not covered in the submission because too subtle. But I am sure this important… the anti-vapers are trying to define their enemy in a way that makes it easier for them to oppose and to arouses the public’s deep conflation between smoking and vaping and between smoking and nicotine. Strawberry cheesecake breaks all that.

      I suspect if there had only been tobacco flavours from the outset, they would be claiming that these are ‘trainer products’ for youth.

      It is a particularly spiteful thing to do to users who are trying to get away from tobacco – we know that users migrate over time to non-tobacco flavours and can begin to dislike tobacco. What a good idea to force them back – either to tobacco c=flavouring or to the real thing.

  • John walker

    Clive another aspect is the term tobacco flavour as best as I all tobacco flavoured liquids are not flavoured with some kind of , extract of actual tobacco, rather they are made by combining various off the shelf flavour essences. So the proposed rules would seem to be based on a arbitrary definition of what ,kinds of mostly synthetic flavour essences can be combined and what they can be ,called.
    As best as I know it governments do regulate the potentially ten of thousands of flavour aroma essence combinations re general safety but not what they taste like, let alone what they are called for good pragmatic reasons , it’s too hard.

    • Yes, I agree this will be difficult to specify. We didn’t go into the way that the NL proposal is implemented – a white list of permitted flavour ingredients rather than subjective assessment of flavour. This is the most restrictive way to do it – but let’s see what ends up on the list. I guess they will allow natural extracts of tobacco.

      • John walker

        Clive curious aspect of this is in order for a ban on ‘non tobacco’ flavours to be effective they would also have to ban ,unflavoured liquids .
        Re uglification they basically wish that vaping really was the same as smoking particularly that it had the same strong easy to detect lingering smell .

        • Roberto Sussman

          What we call “flavors” are combinations of chemicals that simulate a specific aroma. Even “flavorless” e-liquids (containing only the essential PG, VG and nicotine) have a flavor defined in this sense. VG has a sweetish aroma and taste. In a strict flavor prohibition in practice the regulators would select one combination of chemicals added on top of the essentials, which to them would smell or taste like tobacco and forbid any other combination. To be legal all e-liquids would have to be lab tested to verify that other chemicals are absent (this is a standard lab procedure in analytic chemistry).

          However, the selection of chemicals to mimic tobacco is entirely subjective and arbitrary, since no real tobacco is involved and none of the tobacco flavors simulate tobacco with 100% accuracy. In fact, it is far easier to simulate strawberry, a fruit, than tobacco smoke (it is not a simulation of the tobacco leaf but of tobacco smoke, whose chemistry is entirely different).

          Here the “uglification” could come in selecting a chemical combination simulating the worse possible aroma, irritant and unpleasant. When you have a powerful tobacco control and regulatory technocracies who so much dislike (or fear) a product, anything is possible to hurt and denigrate the product.

        • VERY well analyzed Roberto!

          It is important to remember that none of the Antismokers’ arguments are ever actually real in terms of them being the essential arguments concerning health that they claim to be.

          The motivating factor behind every argument that they use will always be simply seeking to exploit any vulnerability they can find that will advance them toward their ultimate goal of total elimination of anything that involves or smells like or looks like anything at all to do with smoking from the face of the earth. If you look back at their history over the last 40 years You will see that each and every time a real opportunity presented itself they have simply tossed aside any claim they had previously made about not seeking to impose more restrictive regulations as they aim their weaponry at the new weak spot of the moment.

          You could develop vape liquid with the purest scent of heavenly ambrosia, and they would simply take it as an opportunity to claim that you were trying to attack and addict innocent children with the new flavor.

          -MJM

  • One consistent problem with responses like this (admitting that I only read the summary here, but these are all pretty much the same) is muddling normative and positive arguments. Not that those who are being criticized do not do that even worse, but if the goal is to clarify, then doing that is a particularly bad idea.

    So it is clean to say “if the goal is to reduce smoking then this is a bad policy because….” You can write a paper on why claims that this policy will reducing smoking are baseless. And another paper on why it is probably counterproductive. But what does not work is saying “this is bad because it will not reduce smoking [subtext: because we all agree that the primary goal that trumps everything else is reducing smoking, right?]”.

    Not everyone has that as their only goal or their primary goal, or even agrees with it at all. That includes many of the people who write advocacy with words that imply it is their goal. “I personally don’t like this policy because it will….” is fine. “This policy is existentially bad because it will….” is the same type of rhetoric that is used to endorse such policies.

    A good starting place for remedying that common problem that public health academics have (“how could anyone possibly have a different goal than I do???”) is to pause to ask: “Perhaps the advocates for X [analogy: people who do X] are not stupid or misinformed, but actually have different goals than I do. What can I infer about their real goals if I assume that this proposed policy fulfills them even though I do not like it?”

    • I don’t really know what you are you are referring to in the submission, as you haven’t actually said.

      The goal here is to reduce harm. I’m not going to spend time justifying that. I don’t think it is ambiguous, controversial or needs restating. I favour THR because it is an approach that reduces health harms primarily through reducing smoking but without inflicting other harms (economic, social, stigma, hedonic) and with many benefits, which is also why it works.

      Bear in mind, this is written for a government consultation, in which a target, “smoke-free by 2040”, is the guiding objective. When you are trying to influence something (rather than just declaiming), it is important tactically to determine what is common ground and what you can plausibly challenge. That goal cannot be realistically challenged in this consultation and would lead to an effortless dismissal by critics and the government. However, the approach to achieving it and the scope-creep from smoking to nicotine absolutism can and should be challenged.

      As I have said before, ‘smoke-free by 20xx’ would be a reasonable objective if it came about through changes in a regulated marketplace, improving technology choices, guided by consumer volition. The alternative would draw the government towards punitive measures and prohibitions – this is one example – and the consultation response aims to address that.

      PS. There’s still time (until 2 Feb) to respond. You could write your own submission.

      • So your reply might be interpreted as “haha, you said smoke-free and vapor is not smoke, so here is why you are not fulfilling your goals”, to which the response is “fine, whatever. we really meant tobacco-free [or nicotine-free or recreational nicotine free or whatever], so your comments are misguided.” You can make a good argument of “we believe your goals are bad and really should be reduced total harm because…”, but when that political preference is presented as just going without saying and muddled in with scientific analysis, it is neither clear nor effective. Inferring their real goal from what their actions will probably cause and confronting them about that goal is different from declaring the possibly goal is something the policies do not further. Of course, there is a good chance that the inferred gaol is not exactly what they are hoping for, but moving at least somewhat in that direction from just assuming all the consequences you do not like are the result of bad policy engineering seems wise.

        I doubt I will write my own submission. I write a ton of material that people can use in their submissions. I see some hints of it appearing in what you submitted. I will leave the actual submitting to others.

        • I don’t know what you are talking about. This doesn’t make any sense or refer to anything I said – only to things incorrectly paraphrased in your imagination.

          I worked pretty hard on it, I’m pretty happy with it, and, right now, I can’t be arsed with obtuse negativity.

          Good night.

        • I was not intending to be negative. Your comment was undoubtedly more effective (in terms of the goal of persuading the target people) than anything I write would be. I’m sure it is potentially the best thing that will be submitted in the whole process.

          Please let me try again:

          It is potentially more effective in terms of the immediate politics (and is much better in terms of creating a definitive response to all this stuff) to do more to sort out the following distinct bits of reasoning, evidence, and opinion:

          -You claim you are pursuing [objective function] but what you propose will not do it because…

          -You seem to also/really be pursuing [other objective function] but that is not an ok goal for government because [ethical theory] and [popular opinion that we the authors share]

          -But even for [other objective function] this particular intervention is not optimized because…

          -In addition, an exclusive focus on either of those objective functions will [downsides that are not addressed in the objective function or perhaps even acknowledged] which should be considered also

          -Here is what we think the goal should be and what we happen to think is the best way to achieve it.

          My concern is that when those are muddled together, people will tend to read it as being all about the first and last of these and jump immediately to “here is someone with different goals than we have, so naturally they do not like our proposal, but they do not share our goals so we can just stop there and say “nope, we disagree with your normative assertions”.

  • Louise Ross

    Thanks as always for the clarity you bring, Clive; this looming prohibition is appalling to watch

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