On behalf of the Tholos Foundation, a non-profit organization which advocates in the interests of taxpayers and consumers across the globe, we offer these comments in response to the European Commission initiative to evaluate the legislative framework for tobacco control. We strongly encourage the European Commission to embrace the benefits of tobacco harm reduction and make clear, through language and legislation, that vaping is a reduced-risk alternative to cigarette smoking. Adult consumers throughout the EU deserve legal access to life-saving vaping devices.
Further, this submission presents evidence in support of snus, heat-not-burn devices, and other oral nicotine products. These products are additional examples of reduced-harm alternatives to smoking with scientifically demonstrated health benefits. Adult access to these goods saves lives and promotes a healthier Europe.
All evidence presented in this submission is based entirely upon scientific studies and analysis from the world’s top researchers. We urge you to consider this science and develop policy that encourages adult consumers across the European Union to transition to safer products.
Evidence for Vaping as a Reduced-Risk Alternative to Cigarette Smoking:
There is overwhelming scientific consensus in support of e-cigarettes as smoking cessation devices and they have produced outstanding results in many countries. Regulating them as such will encourage EU cigarette smokers to make the switch to e-cigarettes. This will drastically improve health outcomes across Europe and help decrease socioeconomic disparities.
Contrary to popular belief, e-cigarettes are not a product invented by tobacco companies. In 2001, a Chinese man called Hon Lik, a cigarette smoker himself, created the world’s first e-cigarette after his father succumbed to lung cancer caused by deadly cigarettes. The major difference between e-cigarettes and traditional cigarettes is how the “smoke” is created. In cigarettes, a combustion process creates smoke. This process is what produces many of the harmful chemicals that cause cigarette smokers, and innocent bystanders, to be subject to significant damage to their health.
E-cigarettes do not have a combustion process, and therefore do not emit many of the dangerous chemicals that are present in combustible cigarettes. As a result, e-cigarettes are a significantly less harmful way of consuming nicotine. According to a study from Public Health England, e-cigarettes are at least 95% less harmful than traditional cigarettes.A separate, comprehensive analysis of the harm of different nicotine products estimated that e-cigarettes contain just 4% of the harm of cigarettes.
According to a study by the American Heart Association, switching from smoking to nicotine vaping lowers the risk of stroke by 84%. The same study found that the heart health biomarkers of e-cigarette users are similar to, or indistinguishable from, people who had never smoked a cigarette. The United States National Academies of Sciences, Engineering, and Medicine stated “there is conclusive evidence that completely substituting e-cigarettes for combustible tobacco cigarettes reduces users’ exposure to numerous toxicants and carcinogens present in combustible cigarettes”.
Additionally, statements in support of e-cigarettes have been released by over 100 public health organizations across the globe. This list includes the British Medical Association, New Zealand Ministry of Health, Royal College of Physicians, French National Academy of Medicine, the American Heart Association, and many more.
Of particular importance, the European Parliament adopted, by a margin of 652 to 15, a report acknowledging that “electronic cigarettes could allow some smokers to progressively quit smoking”. Scientific evidence shows electronic cigarettes help many smokers quit, even when they do not intend to.
Evidence for Vaping as a Crucial Tool of Smoking Cessation:
It is important to note that it is the combustion, not the nicotine, that causes disease and cancer among cigarette users. Nicotine is a relatively benign substance like caffeine that “does not result in clinically significant short- or long-term harms”. Nicotine replacement therapies, like gums or patches, have been available for decades but often fail in their mission of helping smokers quit. E-cigarettes mimic the habitual nature of smoking while creating vapor, rather than harmful smoke, which does not contain the deadly carcinogens present in tobacco.
There is ample evidence to suggest that cigarette smokers will be willing to make the lifesaving switch to e-cigarettes. A recent study found that a smoker who attempts to quit with an e-cigarette has an estimated 323% higher chance of achieving complete cessation compared to someone using a traditional nicotine replacement therapy like patches, gum, or oral spray. Another study found that e-cigarettes are more than two times as effective at getting smokers to quit than traditional nicotine replacement products.
E-cigarettes have a demonstrated ability to reduce smoking. In the United States, the adult smoking rate was 21.6 when e-cigarettes entered the market in 2003. Due to increased access to vaping, the U.S. adult smoking rate has plummeted to 13.7% as of 2018. In the United Kingdom, a new analysis from 2021 by Public Health England demonstrated just how effective vaping is in helping people quit smoking, noting that in just one year, over 50,000 British smokers, who would have continued smoking otherwise, quit smoking with vaping.
In France, a proud member of the European Union, vaping is a recommended method of quitting cigarette smoking. For the benefit of public health, the EU should embrace France’s public health policies regarding e-cigarettes and consider them as tools for smoking cessation. A study from Colin Mendelsohn of the University of New South Wales found that countries that adopt harm reduction policies regarding nicotine see greater reductions in cigarette smoking than countries that don’t embrace the lifesaving benefits of e-cigarettes.
Vaping as a Method of Reducing Socioeconomic Disparities:
Scientific studies have shown that e-cigarette use can “reduce health disparities”. The reason for this is smoking rates are historically highest among those with lower income and less education. This will “translate directly into lower medical costs” and would produce “an improved quality of life” for these disadvantaged populations.
A study from Dr. William Stephens of St. Andrews University, published in the British Medical Journal, showed that the risk of cancer from e-cigarettes, compared to that of smoking, is less than 0.5% percent. Increased access to e-cigarettes among people of lower income will come with decreased cigarette consumption. This will decrease cancer rates among these populations, many of whom would face financial or other obstacles to getting the medical care they need.
Additionally, there is scientific evidence that nicotine-containing e-cigarettes dramatically help people with mental health issues quit smoking, even when they have no desire to quit. For people who suffer from schizophrenia, vaping has a demonstrated ability to better their mood, make them feel more awake, less irritable, and have improved concentration. These communities smoke at rates three to four times higher than average. Efforts to increase smoking cessation among people with mental health issues must be a major priority.
Embracing tobacco harm reduction throughout the European Union will offer underserved communities across the continent a method of decreasing the harm they are subjected to by cigarette smoking. This will reap benefits for public health throughout the EU.
Prohibitions Weaken National Security and Decrease Tax Revenues
Prohibitions, which occur when governments ignore the overwhelming evidence in support of e-cigarettes, promote illicit markets for these products and can have deadly consequences. Tobacco and nicotine-product smuggling is largely run by highly organized, international crime syndicates.
These organizations use their smuggling profits to fund more nefarious activities including human trafficking, money laundering, and terrorism. Because of this, the U.S. State Department has explicitly labelled tobacco smuggling a “threat to national security”. Illicit products also lack the regulation and safety standards of legal products.
In addition to the threat of a thriving black-market, prohibitionary policies lead to reduced tax revenue which weakens a nation’s fiscal flexibility. In countries like Estonia, where flavored products are banned, e-cigarette users have turned to the black-market in droves in search of flavored vapes. According IPSOS polling, commissioned by the Tholos Foundation, almost 60% of Estonian vapers still use banned products. Many of these users either purchase illicit products or mix their own nicotine liquid, a dangerous practice.
For every vaper who purchases their product illicitly, the Estonian government loses out on tax revenue. With more than half of Estonian vapers using untaxed goods, the expected tax revenue decrease is massive. The European Union would be wise to reject prohibitionist policies that would increase the scope and power of international crime syndicates while tax revenues decrease. Through the adoption of pro-vaping policies, the influence of these criminal groups will be diminished, and governments will be able to collect healthy tax revenues to fund important domestic projects or offer tax relief to citizens.
Evidence in Favor of Snus, Heat-Not-Burn Devices, and Other Oral Nicotine Products
In Sweden, men use more smokeless tobacco than any other country. As such, they have the lowest rate of lung cancer in the developed world. The smokeless tobacco used in Sweden, commonly called snus, is a clean tobacco product. This means that it contains significantly less toxins than other tobacco products. In the United States, the Food and Drug Administration (FDA) has granted a “reduced exposure” marketing authorization for eight different snus products. This allows the labels of these goods to state that use “puts you at a lower risk of mouth cancer, heart disease, lung cancer, stroke, emphysema, and chronic bronchitis”.
FDA’s decision is rooted in scientific evidence stemming from significant research that shows snus is a significantly less harmful product than combustible cigarettes. FDA has also authorized heat-not-burn (HNB) products to be sold with “reduced exposure” marketing. HNB’s heat tobacco, rather than burning it, which creates a vapor. The vapor, because it has not undergone the combustion process that creates smoke, contains less toxic chemicals than cigarettes.
A 2021 study found that HNB’s emit 87.4% less carbonyl compounds than a conventional cigarette. Carbonyl compounds are incredibly harmful. Some examples include formaldehyde, acetaldehyde, and acrolein. The same study determined that HNB’s produce 96.2% less polycyclic aromatic hydrocarbons than a conventional cigarette. Continued exposure to these chemicals can lead to lung, skin, and bladder cancer.
HNB’s are also shown to be extremely useful at helping smokers quit. In Japan, where HNB products are popular, cigarette sales fell by 43% over five years as a direct result of increased HNB use. There is no reason to believe that the same incredibly health improvements found in Japan can’t be replicated in Europe. It would significantly decrease harm for nicotine users, maintain tax revenues, and ultimately save lives.
Nicotine pouches are another reduced-risk product that the EU would be wise to accept as a harm-reduction tool. These pouches are often completely tobacco-free and contain only nicotine, food-grade ingredients, and plant fibers. The toxicant profile of these pouches is shown to be less than that of snus. Pouches contain only trace levels of harmful chemicals, exposing users to a tiny fraction of the harm of other nicotine-containing products.
The Tholos Foundation strongly encourages the European Union to follow the science and enact policies that embrace harm reduction. As the evidence presented in this submission shows, there are numerous reduced-harm alternatives to cigarettes that offer cigarette smokers the nicotine they are dependent upon without the extensive harms of combustible tobacco. They offer people who smoke the greatest chance of quitting their deadly habit and it would be unconscionable to enact policies that would reduce adult access to these products.
E-cigarettes, snus, heat-not-burn devices, and oral nicotine products have the potential to save millions of lives across Europe. The Tholos Foundation believes that all decisions concerning public health must be based upon scientific evidence and proven facts. The science is clear, vaping and other alternatives are the best path towards a smoke-free Europe.
In the interests of public health, improving the European economy, and reducing socioeconomic disparities, we offer this submission in support of tobacco harm reduction and adult access to reduced-harm alternatives to cigarettes.
Consumer Issues Fellow