Reducing tobacco smoking related harm

Strategies of reducing the amount of harmful ingredients can also be found with regards to tobacco products, where ‘light cigarettes’ were introduced with the claim that this would help to reduce health risks related to tobacco smoking.

Like with light alcohol products the introduction and promotion of so-called ‘light’ cigarettes was predominantly an initiative of the producers. In many countries the use of the term ‘light cigarettes’

was banned as misleading. The filters of these light cigarettes are prepared with small holes in them.

Smoking machines controlling the tar and nicotine intake during smoking measure lower levels of both harmful substances, because additional air is inhaled through these holes. However, in a real life setting smokers prove to adapt their way of smoking, by closing the holes with their lips and fingers. They then inhale as much as they need to reach the nicotine level they are used to. In practice, the amount of tar inhaled may become even higher with these ‘light’ cigarettes than with regular cigarettes (Kozlowski and O'Connor 2002).

In the field of tobacco harm reduction options seem to be limited despite the fact that tobacco smoking is uniquely harmful, as it causes serious health harms, even when used exactly the way the manufacturer recommends. Nevertheless, harm reduction options would be useful since there are many chronic smokers who are unable or unwilling to become abstinent. Tobacco harm reduction focuses on ways to lower the health risks associated with using and particularly smoking tobacco.

20 STIVA – Dutch Foundation for the Responsible Use of Alcohol (2001). ‘Deterring Drinking and Driving’. Available at:

http://gsri.worldwidebrewingalliance.org/php/initiatives/initiative.php?ini_id=439; CNW (2013). New Budweiser campaign backed by ground-breaking research on designated drivers. Available at:

http://www.newswire.ca/en/story/1204065/new-budweiser-campaign-backed-by-ground-breaking-research-on-designated-drivers [accessed 13 October 2013].

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The available evidence shows that reducing the number of cigarettes smoked per day does not substantially reduce the risks of cancer and cardiovascular problems and can therefore only be advised as a step towards complete abstinence. Other options include switching to snus or dipping tobacco (a moist powder tobacco product originating from a variant of dry ‘snuff’ which emerged in the early 19th century particularly in Sweden). This product is forbidden in European countries, except for Sweden. Non-tobacco nicotine delivery systems (plasters, chewing gum) can be used as part of smoking cessation, but are not intended for long-term substitution. Recently, many other alternatives appeared on the market, of which the electronic cigarette or e-cigarette is the most interesting example.

The emergence of the e-cigarette

The e-cigarette is a battery-operated device emitting doses of vaporized nicotine, flavour and other chemicals that are inhaled in a way that mimics tobacco smoking. E-cigarettes were already developed in the late 1960s. The first commercially produced e-cigarettes came onto the market in China in 2004. Today they are available in many countries, including the USA, Europe and South America. They are increasingly popular and therefore also interesting for the industry. While the first e-cigarette brands were produced by small independent companies, today their production has become ‘big business’. The tobacco industry too became interested in the e-cigarette production.²¹ From the start there has been debate concerning appropriate ways to regulate these products.

Central question is whether this product is just a recreational smoking product that may be less harmful than regular cigarettes, or a device that can be helpful in reducing conventional smoking or even an aid in quitting, or a gateway to smoking for non-smoking youth.

The debate pro and con the e-cigarette: reducing or inducing harm

This last concern increased when the tobacco industry was found to be interested in the product and started to buy a number of companies that produced e-cigarettes. This was seen as an attempt to make up for the decrease of traditional tobacco smokers.²² Opponents of the e-cigarette warn not to make the same mistake as with tobacco: the e-cigarette is an addictive product that should be strictly controlled or even banned. They point out that the information provided by the industry should not be taken too serious as the interest of e-cigarette producers is profit making and not the health of the consumers.

Proponents argue that the e-cigarette brings the long awaited solution that may substantially reduce tobacco use. Proponents of the e-cigarettes, including their producers, users, some health policymakers and some health professionals, claim that by delivering nicotine directly to the lung, they are more effective and acceptable than nicotine replacement medicines, and should be readily available as cigarette substitutes. They claim that in doing so, the harmful consequences of smoking tobacco due to toxic ingredients like tar, carbon monoxide and other carcinogenic substances would drop dramatically. Proponents also argue that e-cigarettes deliver the experience of smoking while eliminating the health risks (and the smell) associated with tobacco smoke, thus also solving the problem of passive smoking (Polosa et al. 2013).

Although the e-cigarette has been marketed by its advocates as “not containing any toxins”, producing “no first or second hand smoke”, not containing “cancer causing chemicals as found in

21 http://www.businessinsider.com/e-cigarettes-will-be-3-billion-market-2013-5 [accessed 18 January 2014].

22 http://www.cbsnews.com/news/tobacco-companies-bet-on-electronic-cigarettes/ [accessed 18 January 2014].

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tobacco cigarettes”, producing “simply water vapour” and helping to “quit smoking” (Henningfield and Zaatari 2010), its opponents point out that the health effects of inhaling and exhaling vapour containing nicotine and other additives into the lungs are still a subject of uncertainty. Overall, there are only few controlled studies available investigating the benefits and possible risks of the use of the e-cigarette (Etter and Bullen 2011). At the time of writing this report the possible short and long-term health effects of inhaling nicotine vapour and other substances into the lungs are unclear.

Opponents express their concern about the carcinogenic properties of nicotine, the inhalation of propylene glycol and flavours, the impurities in the e-liquid with toxic substances and also the behavioural effects of the e-cigarette. Since e-cigarettes do not produce ‘smoke’, many countries allow their use in smoke-free areas. Arguments against the introduction of e-cigarettes are that they might undermine the aims of policies to reduce smoking as laid down in regulations and laws. The e-cigarette might be a fancy product that re-normalises smoking. It also might work as a gateway to smoking.

Worldwide millions of tobacco smokers have tried e-cigarettes or used them more regularly. A majority of 69 per cent of EU citizens knew about e-cigarettes in 2012.²³ Around 38 per cent stated that they do not know if cigarettes are harmful or not. Seven per cent of EU citizens have tried e-cigarettes. Although the number of users in Europe is still small, this number might increase in the near future. The available research shows that currently many e-cigarette smokers use it instead of the conventional nicotine replacement therapy such as plasters or gum. Users ‘vape’ the e-cigarette to avoid relapse, as an aid in reducing and / or cessation of conventional cigarette smoking.

Nevertheless, opponents are concerned over the increasing number of young non-smokers trying the product. Still, there is no ‘hard evidence’ that the product functions as a gateway to smoking of conventional cigarettes. Youth tend to experiment, and some argue that young people can better experiment with the less harmful variant than with conventional cigarettes which are known to be highly addictive. Opponents also point at the lack of quality control of the product.

Although it was found that there are some e-cigarette brands of high quality design and manufacture, for most e-cigarettes there is no guarantee that the chemical composition is consistent and follows regular quality standards. There is also a lack of government set standards for acceptable designs, ingredients concentration, level of purity, safety and recommendations for safe use (Schaller et al. 2013).

The lack of evidence-based information on the e-cigarette (its toxicological aspects, its potential to support cessation, the possible gateway to smoking) limits policymakers’ ability to evaluate the potential public health consequences of their use.

In some countries, such as Australia, Brazil, Canada, Denmark and Switzerland, e-cigarettes are banned. The most frequently used arguments for this decision are that nicotine is a poisonous substance and that manufacturers have not provided any scientific evidence that the products are a safe and effective form of smoking cessation therapy, such as other nicotine replacement products.

In some countries, such as Brazil, public consultation, including participation of consumer protection agencies, was an important component underlying the decision. Other countries, including the USA, are wrestling with regulation. In Europe, there are different responses on national as well as on European level (Magaldi 2014).

23 http://ec.europa.eu/public_opinion/archives/ebs/ebs_385_en.pdf [accessed 14 January 2014]

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Lack of evidence for decision making: zig-zag policy in the Netherlands

The popularity of e-cigarettes has increased in the Netherlands in recent years. The use has tripled in 2013 compared with 2012. The last figures show that 3 per cent of the general population in the Netherlands (15-75 years) is smoking e-cigarettes.

There is a widely shared consensus that availability of e-cigarettes should be regulated. However, the novelty of the product interferes with well-founded, consistent policy decisions. In the Netherlands, the e-cigarette came on the market in 2007. Since the product did not contain tobacco, or parts of tobacco, it did not fit in the Tobacco law and was classified under the Commodities Act (Warenwet).²⁴ Tobacco laws in some other countries do not stipulate as condition that products have to contain (elements of) tobacco to be included under this law. E.g., in Belgium the Tobacco law also poses a ban on similar products and elements that can put someone up to smoking or give the message that smoking is allowed. Belgium therefore classified the e-cigarette as medication. Norway banned all new types of tobacco or nicotine-containing products.²⁴ In January 2008, the Dutch Minister of Health declared that consumers should be able to take it for granted that the e-cigarette is a safe product and decided to bring the e-cigarette with a provisional regulation under the Medication Law.²⁵ Manufacturers had to register the product at the Medicines Evaluation Board and at the same time an official ban on advertising came into force. This was challenged before court by an e-cigarette producer. However, the judge decided to maintain the advertisement ban, arguing that it was rather likely that the e-cigarette would be classified as medication and the company was free to try to have the e-cigarette registered by the Medicines Evaluation Board.²⁶ The Minister of Health did not decide at that time on a permanent legal status of the e-cigarette, as he was awaiting a decision on European level.

Almost four years later, in December 2011, the (new) Minister of Health formally classified the e-cigarette as medication, although a collective European decision was still not taken.²⁷ She argued that a product can be classified as medication based on the way it is presented and / or because of its action. According to the Minister, the e-cigarette was to be classified as medication because of its action. Using pharmaceutical expertise, pure nicotine is isolated, stored in cartridges and administered through inhalation to cause relaxation or stimulation. Comparable products such as nicotine gum, lozenges, patches and inhalers were already previously classified as medication by the Medicines Evaluation Board. However, the industry again challenged this decision in court and the court decided in their favour.²⁸ This decision was based on the arguments that a fundamental difference between the e-cigarette and the nicotine inhaler is that this last one is presented as medication, while there are no medical claims on the e-cigarette. Further, the court argued that the pharmacological effect is not larger than from the conventional cigarette and public health risks are certainly smaller than for the conventional cigarette.²⁹ As a result, the e-cigarette is back in the Commodities Act since mid-2012.

24 Heijndijk, S. De juridische status van de elektronische sigaret in Nederland: een overzicht van de zoektocht naar een passend wettelijk kader. Oral presentation at the First congress of the Netherlands Network for Tobacco control; Utrecht, November 29, 2013.

25 http://www.rijksoverheid.nl/nieuws/2008/01/28/klink-elektronische-sigaret-op-europese-agenda.html [accessed 14 January 2014]

26 http://www.rijksoverheid.nl/nieuws/2008/02/08/reclameverbod-e-sigaret-gehandhaafd.html [accessed 14 January 2014].

27 http://www.rijksoverheid.nl/documenten-en-publicaties/kamerstukken/2011/12/23/kamerbrief-status-elektronische-sigaret.html[accessed 14 January 2014].

28 Arrest van 26 juni 2012, ECLI:NL:GHSGR:2012:BW8660

29 Heijndijk, S. De juridische status van de elektronische sigaret in Nederland: een overzicht van de zoektocht naar een passend wettelijk kader. Oral presentation at the First congress of the Netherlands Network for Tobacco control; Utrecht, November 29, 2013.

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With increasing knowledge over time, also the commotion about the possible health risks increased.

In the second half of 2013, several publications on health implications of e-cigarettes intensified the discussion. The National Institute for Public Health and the Environment (RIVM) produced a fact sheet which warned against carcinogenic substances such as formaldehyde and tobacco-specific nitrosamines in the liquid, and misleading or unproven claims about the health effects of e-cigarettes. They also warned against the dangers of large doses of nicotine, the possible hazards of exhaled vapour, the lack of accurate information on the packages, and irritation of the respiratory system for the user.³⁰ The Nederlandse Voedsel- en Waren Autoriteit (NVWA, Dutch Food and Consumer Products Safety Authority) also warned about the dangers of opening cartridges by children, the health risks of nicotine for pregnant women and the possibility that the e-cigarette functions as a gateway to smoking.³¹

On the other side were the users suggesting that the negative information was lobby work from the tobacco and pharmaceutical industry, and also claiming that the government was looking for extra tax incomes.³² They posted messages such as "do not listen to the National Institute for Public Health and the Environment if you want to stop smoking”.³³ The State Secretary (now responsible for the tobacco files), decided to elaborate additional measures in the Consumer Law on the e-cigarette.

One of these measures is an increase in the minimum age to 18 years for the sales of e-cigarettes.

Many other measures are yet expected to come. This topic is rapidly developing and is far from settled.³⁴

Lack of evidence for decision making: hesitant policy in France

As in the Netherlands e-cigarettes are widely available in France. In France some prevalence data are available. In 2013 the ETINCEL - OFDT electronic cigarette survey showed a lifetime prevalence of 18 per cent among the general population (15–75 years). Interestingly enough, nearly all of these

‘lifetime users’ were tobacco smokers (75 per cent) or former tobacco smokers (16 per cent).

Although a relatively high number of young people aged 15 to 34 had tried an electronic cigarette, they rarely seem to become regular users: only 10 per cent of lifetime users in this age group used daily.

However, older French people were less frequently lifetime users but became daily users more often once they had tried it (26 per cent of people aged 50 to 75 years stating that they had tried an electronic cigarette vaped every day). Lifetime use by older people is undoubtedly less related to curiosity than to their smoking history and their need to find a solution for their addiction.

An interesting finding is that 1.2 per cent of the former smokers in the survey sample stated that they think that they definitely stopped smoking ordinary cigarettes (Lermenier and Palle 2014;

Appendix 1). The available research data in France also point in the direction of an increasing popularity of e-cigarettes.

30 http://www.rivm.nl/dsresource?objectid=rivmp:230704&type=org&disposition=inline&ns_nc=1 [accessed 14 January 2014].

31 http://www.nvwa.nl/actueel/nieuws/nieuwsbericht/2041661/houd-navulverpakking-e-sigaret-met-nicotine-uit-buurt-van-kinderen [accessed 14 January 2014].

32 http://www.esigaret.nl/forum/ [accessed 15 March 2014].

33 http://www.trouw.nl/tr/nl/6849/Sylvain-Ephimenco/article/detail/3555662/2013/12/03/Luister-niet-naar-RIVM-neem-een-e-sigaret-als-je-wilt-stoppen-met-roken.dhtml [accessed 14 January 2014].

34 http://www.rijksoverheid.nl/documenten-en-publicaties/kamerstukken/2013/12/20/beantwoording-kamervragen-over-een-minimumleeftijd-voor-de-verkoop-van-e-sigaretten.html [accessed 14 January 2014].

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Like in the Netherlands the policy response to this new phenomenon is not decisive. Also here the uncertainties about the effects of e-cigarette smoking on health and on smoking behaviour (initiating smoking, substitution of regular cigarette smoking, etc.) played an important role. Till 2013 nothing much happened. Then, in May 2013, an expert report was presented to the Ministry of Health. Also the (work on the) EU Tobacco Products Directive marked a change to a less hesitant policy response (Appendix 1). The most recent governmental Cancer Plan (2014-2019) promotes research into the toxicity of e-cigarettes and their usefulness for smoking cessation. A governmental plan on tobacco is expected to be released later in 2014 possibly promoting measures for regulating the market of e-cigarettes (Appendix 1).

The emergence of EU regulations

This debate about whether and how to regulate e-cigarettes is also conducted at EU level. In 2013 a revision of the Tobacco Products Directive was finally prepared, extending the scope of the Directive to new products like the e-cigarette (Directive 2014/40/EU …). However, the debates about the best regulatory framework went far from smoothly. In fact, the issue how to regulate e-cigarettes resulted in a serious conflict, threatening to disrupt the overall reform of EU tobacco rules in the final weeks of negotiations. There were opposing proposals from the Member States (favouring regulation as a medicinal product) and the European Parliament (in favour of regulation as a consumer product). The conflict nearly escalated to the point that e-cigarettes would be simply removed from the proposal for a revised Tobacco Products Directive, to avoid that the entire package would fail. That would have been in line with the arguments of the e-cigarette proponents, who argue that the product doesn't belong in a Tobacco Products Directive because it contains no tobacco. A compromise was reached at long last, stating that EU law will regulate e-cigarettes as general commodities, while Member States may classify them as pharmaceuticals, if they wish. The European Parliament still has to vote on the deal, and the health ministers have yet to sign the agreement. At the time of writing this report, no major changes in this compromise are expected. The process at EU level is one of a rapidly changing sequence of sometimes diametrically opposed proposals. This may have to be ascribed to the active lobbying of different stakeholders which play a highly important role in this field and sometimes seem to be able to completely change the outcome of policy debates, as can be taken from the following.

The first proposal of the Member States was in favour of strictly regulating e-cigarettes as medicinal devices. Products above a certain nicotine threshold were only to be allowed if authorized as medicinal products. The main arguments of the Member States for this restrictive approach were concerns about possible yet unknown long-term health effects. However, e-cigarette manufacturers, supported by a growing number of e-cigarette users, actively lobbied against this medicinal regulation. At the time the European Parliament favoured regulation as general consumer product.

They endorsed a permissive approach to the sale and use of e-cigarettes. Nevertheless, this proposal stated that the products should not be sold legally to anyone younger than 18 and tight restrictions on advertising and sponsorship should be in place, similar to those for regular cigarettes. The outcome of this debate was the compromise described above, in which the EU classifies the e-cigarette as a consumer product, while Member States are free to classify them as pharmaceuticals.

A second controversial issue has been the refillable cartridge. This issue was also solved by means of a compromise. Refillable e-cigarettes will not be banned for the time being, but this may change in the coming years, if Member States would ban them for safety reasons. In the controversy was that the Member States demanded an EU ban, while the European Parliament did not. The Member States expressed their concern that the cartridges are unsafe, among others because of unreliable nicotine content. Members of the European Parliament on the contrary, representing at least partly the voice of e-cigarette producers and users, argued that the wide range of refillable cartridges suits

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the needs of the user. Restrictions would undermine the potential of e-cigarettes as a tool to quit smoking. In the compromise that was agreed, the sale of refillable cartridges no larger than 2 millilitres is permitted. Member States are allowed to ban specific types of cartridges, provided this is justified by safety concerns. If three Member States adopt a ban on a specific cartridge, the European Commission could unilaterally impose an EU wide ban. Manufacturers and users are afraid that this could allow bans on all refillable e-cigarettes through the back door. It fact this compromise implies that in the coming years it is for the national governments to decide whether or not to ban refillable e-cigarettes.³⁵

Despite the tight regulation of the e-cigarette in the proposed revision of the Tobacco Products Directive, it remains unresolved where vaping is permitted. This decision is left to national and local jurisdictions.

35http://europa.eu/rapid/press-release_MEMO-14-134_en.htm [accessed 3 March 2014];

http://www.europarl.europa.eu/pdfs/news/expert/infopress/20140221IPR36632/20140221IPR36632_en.pdf [accessed 3 March 2014]