GE2020 New Nicotine Alliance policy

New Nicotine Alliance Ireland has watched as the four main political parties issued their manifestos. All four mention e-cigarettes and vaping in their policies. From a ban on flavoured products to a vague intention to pass regulation for e-cigs. None offer any justification for their positions and none make any mention of why they feel the need to have a policy. This is deeply disappointing and disturbing.

Smoking is the main cause of avoidable illness in this country. Despite one of the harshest tobacco control environments in the world the rate of daily smoking remains persistently high. Each year 6,000 people die from smoking related illnesses in Ireland, according to HSE figures. https://www.hse.ie/eng/about/who/tobaccocontrol/kf/

Almost €12 million was spent on smoking cessation measures including medications, services, the national quitline and media campaigns in 2017. Yet the loss to the exchequer attributed to the impact of smoking totalled €1.65 billion. https://www.irishtimes.com/news/ireland/irish-news/smoking-costs-state-140-times-more-than-it-spends-helping-people-to-quit-1.3815601

Since the advent of vaping this rate had started to drop, it’s now down to 17% from 23% in 2015 and smoking among under 18 is at it’s lowest historical rate. While it would be foolish to claim this is entirely driven by the rise in vaping, it remains a fact that vaping has not reduced rates of quitting and in fact may have contributed to it’s acceleration.

The current regulation, implemented by Simon Harris in 2016 is working well, smokers have the option of an alternative to combustible cigarettes and are seizing this opportunity in increasing numbers. Any regulation that would undermine this would be counter productive. E-cigs are proven to be one of the most effective aids to stopping smoking. https://www.nejm.org/doi/full/10.1056/NEJMoa1808779

Flavors are integral to that and use of e-cigs pose little risk to bystanders.

Yet, factions in public health want bans on flavors, taxes on vaping equal to combustible cigs and inclusion in smoking bans. One party leader has said he wants to ‘denormalize’ vaping.

What advice are our regulators getting? Who is advising them and why are they ignoring the research available?

As the only voice for consumers, the new nicotine alliance is issuing this policy position which it hopes all political parties and health bodies will read and consider.

The first and most important thing any future government should do is engage with the people who use these products. They are the ones who will be affected and have the greatest stake in any regulatory outcome. The Jakarta declaration from the World Health Organization states ” “increase community capacity and empower the individual” without engaging consumers and by failing to deliver factual information Ireland is neglecting this.

The subject of flavourings.

Combustible tobacco products are banned from having characteristic flavours, either added to the tobacco at manufacture or in capsule form. This restriction does not apply to e-cigarettes or the refills. Right now there are calls for flavours in vaping products to be removed and as this may be discussed in the context of legalisation we would like to address the issue.

First we must establish what ‘problem’ a ban on flavours is intended to solve and whether such a problem exists. We are not saying wait until there is a problem before it’s addressed, rather that we need to be more specific as to the nature and likelihood of the problem before we resort to knee jerk solutions which may do more harm than good.

Two things have contributed to this focus on flavours. The recent cynical and false conflation of nicotine vaping with the outbreak of serious lung injury arising from the use of adulterated illicit cannabis products has caused a panic around vaping, even though – beyond any reasonable doubt – it has no connection to the nicotine inhaling products available here, which are used as smoking replacements.

The second thing driving this flavour issue is the huge media coverage of ‘teen vaping’. Mostly driven by media but aided by some public health bodies who have exaggerated the level of teen use. If based on a misunderstanding or misrepresentation of the level of use, then that needs careful consideration.

The stated claim for a ban on non cigarette flavoured products is usually some variation of “Children are being targeted with colourful and flavoured vaping products.” https://www.oireachtas.ie/en/debates/debate/dail/2019-10-09/15/?fbclid=IwAR0Zvhd4_wajQ9uKpY9PzXZ72UtJO_vzuOLaaVWV0hQZ8PNsKwCkO9qsiS0#spk_98

This is an evidence-free assertion based on little more than ‘I feel it in my water’. Is the claim that adults don’t like flavoured products or that adults don’t appreciate humorous branding? Neither does this offer any evidence that without non-tobacco flavours, teens would abandon vaping and remain nicotine abstinent.

In the US the most popular vaping product with adolescents is Juul. It has 5 flavours and a minimalist graphic design. https://www.juul.ie/

Is this evidence of ‘targeting children’ or evidence that, if anything, more adult orientated marketing attracts adolescents?

The Irish Cancer Society recently presented research claiming to showed adolescents prefered flavoured products and that these flavours were specifically designed to attract them. Apart from the fact that a sample of only 16 adolescents participated and their is no indication any of them were users of e-cigarettes, the main failing of this ‘research’ is it tells us nothing about why adolescents use e-cigarettes and everything about why adults think they use them.

It is worth noting that when asked, adolescents users themselves cited ‘curiosity’ as the main reason for trying vaping, they placed flavors third. Table 5;

https://www.cdc.gov/mmwr/volumes/68/ss/ss6812a1.htm#T5_down

What about adults and their preference?

This study from the US shows fruit, sweet and dessert flavoured products are highly popular with adults. Interest in tobacco flavours has been declining over time as consumers increasingly see vaping as a different experience to smoking and a better way to consume nicotine. Flavours are integral to that experience.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6022703/

Notice also that non-tobacco flavours are mostly used by younger smokers when switching, given the benefits of smoking cessation as early as possible, removing these flavours could postpone smoking cessation until more damage has accumulated?

At this stage I need to point out, most if not all the studies on this subject are from the US, unfortunately, research in Ireland is lacking. We would sugest increasing the motoring of smoking and e-cigarette use to every 6 months. This would yield valuable data with which to inform policy.

We notice that calls for a ban on flavors have moved from ‘kid-friendly flavours’ to a ban on all but ‘classic tobacco flavours’. This shows even the groups and individuals calling for bans have no idea what they want or what action would achieve that result. Is it preventing adolescent smoking? Preventing adolescent nicotine use? Preventing e-cigarettes from becoming ‘normalised’?

If the goal is preventing youth smoking it must be borne in mind that youth smoking is at its lowest historical level, even as youth use of e-cigarettes increases. Page 3 of the Healthy Ireland Survey, Summary Report 2019

https://assets.gov.ie/41141/e5d6fea3a59a4720b081893e11fe299e.pdf

This is also the case in the US, despite the impresion from media coverage.

About 6 of every 100 high school students (5.8%) reported in 2019 that they smoked cigarettes in the past 30 days—a decrease from 15.8% in 2011.”

https://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm

If the aim is preventing youth nicotine use, then are their other options which would be more effective?

If it’s preventing e-cigarettes becoming ‘normalised’, then the question must be asked, Why? If the only answer is ‘We don’t like it’ then legislators must reject the the request.

.

First, let’s examine if youth use is a problem at all. The Healthy Ireland study from 2018, (this year’s full report is not available at the time of writing this), shows an increase in teen use but mostly among teens who already smoke. Among those who never smoked, use is ocasional and less than 1% of never smokers have gone on to become current vapers. We don’t have figures as to whether they use nicotine or not.

https://www.hse.ie/eng/about/who/healthwellbeing/healthy-ireland/publications/healthy-ireland-survey-2018.pdf

Two graphs from Healthy Ireland illustrate the relationship between smoking and vaping, as vaping increases, smoking declines. This shows that vaping is not hampering smoking cessation and instead is giving smokers a route out of smoking.

Note use of e-cigarettes by non-smokers remains at 1%. (red arrows, first pic.)

The data from the US is similar despite the hype around teen use;

Data from the NYTS do not support claims of a new epidemic of nicotine addiction stemming from use of e-cigarettes, nor concerns that declines in youth tobacco addiction stand to be reversed after years of progress. Among current e-cigarette users who had never tried tobacco products, responses consistently pointed to minimal dependence”.

https://www.qeios.com/read/article/391

More regular data is available from the UK and as we share the same regulatory regime, their findings are highly relevant.

data from the 2019 ASH YouGov Smokefree youth GB survey suggest that while some young people, particularly those who have tried smoking, experiment with e-cigarettes, regular use remains low

https://ash.org.uk/wp-content/uploads/2019/06/ASH-Factsheet-Youth-E-cigarette-Use-2019.pdf

The problem is minimal at this stage but monitoring is needed.

Adverse effects of a flavour ban.

The primary adverse effect would be the the closure of hundreds of small to medium-sized businesses (vape retailers and manufacturers) as the products they produce and sell are predominantly flavoured. Loss of jobs, income and with a possible increase in smoking prevalence if users relapse to smoking.

Damage to the product value. Reducing it to an analog of combustible cigarettes without any unique value to attract smokers away from what remains the most deadly form of nicotine use. This is a huge imposition on any consumer product and must be justified by evidence of an actual problem that it addresses, evidence of an overall benefit, and evidence that other less damaging options would fail to achieve the same result.

It is probable that products previously supplied by EU based and regulated suppliers will be replaced by products from the chinese market. For example Fast Tech; https://www.fasttech.com/category/3009

It could lead to more users entering the subculture of DIY mixing of nicotine and food flavours with the associated risk that entails.

Closure of legitimate businesses may be accompanied by the development of black markets that will supply both adults and teens without discretion regarding age. Black market suppliers bring additional risks – they may supply adulterated products made in unsanitary, unregulated conditions (as we have seen with the recent outbreak of lung injuries in black market cannabis products). They may expose adolescents to other black-market products (liquids containing THC or other illicit drugs).

Adolescent users who are current smokers may remain smokers and those who had switched to vaping may return to smoking if non-tobacco flavours are removed. Others may just continue vaping with tobacco flavours while some may quit both vaping and smoking altogether.

The effectiveness of vaping as a smoking cessation option for adult smokers will be reduced or even eliminated. Mitch Zeller head of Centre for Tobacco Products at FDA has admitted as much;

mass market exit of such products would limit the availability of a potentially less harmful alternative for adult smokers seeking to transition or stay away from combustible tobacco products. Dramatically and precipitously reducing availability of these products could present a serious risk that adults, especially former smokers, who currently use ENDS products and are addicted to nicotine would migrate to combustible tobacco products, even if particular ENDS products ultimately receive marketing authorization and return to the market later.” Declaration to the US District Court for the District of Maryland, para 15. June 12, 2019.

https://www.clivebates.com/documents/MarylandZellerDeclarationJune2019.pdf

Inclusion in smoking ban.

We are also aware of some organisations calling for vaping to be included in smoking bans and the minister himself saying he would accept the advice of doctors on this. We do not support any inclusion in smoking bans and argue that as, at worst vaping constitutes little more than a nuisance it should be left to individual proprietors to allow or prohibit as they see fit. There is no evidence of harm to bystanders and no evidence of ‘renormalization of smoking. Including vaping in smoking bans creates a false equivalence between vaping and smoking and could contribute to smokers continuing to smoke. The British Lung Foundation does not support public use bans, https://www.blf.org.uk/your-stories/e-cigarettes

Cancer Research UK state “E-cigarettes do not use combustion and there is no side-stream vapour (i.e. the smoke from the lighted end of the cigarette), so the only source of second-hand vapour is that exhaled by the user. The evidence to date suggests toxicants may be present but at much lower levels in second-hand e-cigarette vapour than second-hand cigarette smoke and there is no convincing evidence of harm to bystanders so far.”

https://www.cancerresearchuk.org/health-professional/awareness-and-prevention/e-cigarette-hub-information-for-health-professionals/safety#E-cigs_safety3

Studies in the US have found “aerosol-free policies was associated with lower odds of ENDS use only in adults aged 25-59 but not young adults (aged 18-24).” This shows that such policy inhibits switching and does nothing to reduce youth use.

https://www.ncbi.nlm.nih.gov/pubmed/31377449

Taxation.

We make the same argument against adding further taxation to vaping products, it sends the wrong message to smokers, that smoking and vaping are equivalent in harm and so inhibits quitting. Evidence from research based on Minnesota’s taxation of vapour products indicates a reduction in smoking cessation.

Our results suggest that in the sample period about 32,400 additional adult smokers would have quit smoking in Minnesota in the absence of the tax

https://www.nber.org/papers/w26589

A Euromonitor report published in 2018, shows Ireland having the 3rd highest per capita spend on e-cigarettes in the world, with a spend of €14.40. Based on these figures, spend on e-cigarettes was almost €70 million in 2018, with the exchequer receiving 23% VAT on all sales.

  • Making vaping more expensive will keep smokers smoking.
  • Taxing vaping creates the impression vaping is as harmful as smoking.
  • There is no practical or principled reason to apply ‘sin taxes’ to vaping products.
  • The value of the health benefit associated with switching from smoking will exceed any benefit arising from revenue collection.
  • VAT is the only justifiable taxation for vaping products.
  • Taxing vaping products ultimately protects the cigarette industry.
  • Vaping products are not tobacco products and do not belong under tobacco tax regimes.

What can be done?

It depends on what you want to achieve, obviously reducing smoking prevalence and uptake of smoking is the primary aim and any regulation should bear in mind that vaping has not adversely affected this aim. Youth use of e-cigs is not something we should encourage and limiting its use in the under 18 demographic must be carefully regulated to be effective. The NNA Ireland suggests a combination of addressing access, advertizing, and messaging as to the place these products have in the campaign for a Tobacco-Free Ireland.

Access;

A prohibition on under 18 purchasing must be a priority. We support the ban on both underage sales and selling. We call for this ban to be supported with enforcement. We want to see regulation on the display and accessibility of vaping products in convenience stores. Currently most stores that sell vaping products among their range of products keep them behind the counter and on display in the space formerly occupied by cigarettes. However some do leave vaping products on open display on the shop floor, pick up and pay at the counter. While this is acceptable for specialist vaping product retailers, it is not acceptable in a general retail environment.

Advertizing;

We support a ban on mass media advertising as a lifestyle product, and exclusion zones for billboard and outdoor advertising.

As branding is part of advertising we call for guidelines on branding and flavour descriptors which may appeal to adolescents.

It is worth noting that in The Irish Heart Foundation focus group, it was found that package design indicated to adolescents the intended purpose of the product.

Clear messaging.

We call for a campaign supporting vaping as a harm reduction element of the Tobacco Free Ireland initiative. We know from the UK where vaping is promoted as such, casting it in this role has not increased youth uptake and may contribute to removing some of its appeal to youth.

https://ash.org.uk/wp-content/uploads/2019/09/Use-of-e-cigarettes-among-adults-2019.pdf

Contrasted with the US approach where public health has aggressively attacked vaping, promoting abstinence only, which has likely resulted in a ‘Streisand effect’ and inadvertently promoted vaping to the very group it sought to discourage.

https://www.shapeamerica.org/uploads/pdfs/2019/publications/ajhe/Vaping-in-the-News.pdf

From the view of public health, the government should truthfully inform the public of the relative risk of vaping products compared to smoking to enable them to choose a safer alternative if they find quitting is not for them. So far no statement from ASH Ireland, the Irish Heart Foundation or any government department has delivered clear information as to the relative risk. This is unacceptable and from a public health perspective, gross negligence.

Again we remind you, the end result of any legislation must be a reduction in smoking and anything that impedes that goal must be rejected. Only measures which contribute to that should be implemented.

New Nicotine Alliance Ireland.

Featured Image credit Lindsay Fox. Ecigarettereviewed.com

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