Summary
We welcome the opportunity to discuss and provide evidence to improve smoking policy, enhance the functioning of the European Union’s internal market, and strengthen public health. At the same time, we are concerned about the evidence base for the Staff Working Document intended to guide revisions to the Tobacco Products Directive 2014/40/EU and the Tobacco Advertising Directive 2003/33/EC.
Our attention is drawn particularly to the Scientific Committee on Health, Environmental and Emerging Risks’ (SCHEER) Opinion on Electronic Cigarettes and Health Outcomes Associated with the Use of E-Cigarettes, Heated Tobacco Products, and Nicotine Pouches by Perez-Cornago et al. under the Publications Office of the European Union.
We focused on these two sources as they represent the most comprehensive collection of evidence behind the Commission’s skeptical position on the benefits of electronic nicotine delivery systems (ENDS), heated tobacco products (HTP), and nicotine pouches. Their arguments are also skewed heavily and incorrectly in favor of treating alternative nicotine products on par with cigarettes, banning flavors, and restricting advertising for these products in general.
For one, the studies cited on the health drawbacks of these products are woefully incomplete. In their literature review, they link nicotine alternatives to cardiovascular-related issues (when either they are far less dangerous than cigarettes or the very opposite is the case), and overestimate the exposure to metals in unlikely scenarios for those vaping and for second-hand smoking. The two articles generally ignore the counter-evidence that, because they are non-combustible and do not contain tobacco, items like nicotine pouches and vapes reduce exposure to cardiotoxic substances by significant orders of magnitude, both to users and to those around them. Not only are these alternatives less harmful, but meta-reviews, population studies, randomized controlled trials, observational academic articles, and contextual findings have demonstrated improved blood pressure, a lower incidence of arteriosclerosis, and better vascular health overall for ENDS, HTP, and nicotine pouches. Sometimes the reports go as far as to claim, as in the case of ENDS, that the secondhand harm or that from inhalation even exceeds that of cigarettes, which has been repeatedly proven to be false.
Moreover, the evidence marshaled by the Commission understates the harm-reduction potential of all three alternatives and overstates the harm from each. Criticism is leveled at some studies (like the Cochrane review) that support harm reduction without an accompanying perspective on the rest of the literature. Alternatively, existing proof is simply not investigated. Any thorough analysis would include the accumulating substantial evidence that ENDS, nicotine pouches, and HTPs help smokers quit, oftentimes more effectively than traditional nicotine replacement therapy.
Finally, both texts revive the flimsy and discredited notion that flavored alternative nicotine products are a “gateway” for adolescents to switch to smoking or more dangerous addictions. The evidence for this claim is based on cohort studies with significant heterogeneity (clumping together 30-year-olds with 14-year-olds in the same analysis). It often ignores the common liability: adolescents who are more likely to transition are those who are more risk-seeking in the first place. Such studies also often remain unaware of bidirectional use patterns in which adolescent smokers often use vapes simultaneously, skewing the underlying data.