In totaal zijn 886 rokers die hulp zochten bij het stoppen met roken geworven. Geen van de deelnemers had bezwaar of ze met behulp van nicotinevervangende therapie (NRT), zoals nicotinepleisters of met behulp van e-sigaretten zouden proberen te stoppen met roken. De rokers werden willekeurig toegewezen in een van deze twee groepen. De eerste groep, 447 mensen, kreeg wekelijkse gedragsondersteuning en een NRT naar keuze (één enkel NRT-product of productcombinaties) De tweede groep, 439 mensen, kreeg een startpakket e-sigaretten en begeleidende ondersteuning over hoe deze te gebruiken. De proef liep van mei 2015 tot februari 2018. De deelnemers zijn gedurende 1 jaar gevolgd om te zien hoeveel er gestopt waren met roken in elke groep. Rokers die e-sigaretten gebruikten, hadden in het begin minder last van de onthouding van sigaretten en hadden op alle gemeten tijdstippen hogere stop percentages.

Na 1 jaar had 9,9% van de deelnemers aan de NRT-groep het hele jaar nog niet gerookt, vergeleken met 18% in de e-sigaret groep. Wat betreft onthouding gedurende ten minste 6 maanden, waren de cijfers 12% in de NRT-groep en 21% in de e-sigaret groep. Deelnemers van de e-sigaret groep vertoonden een aanzienlijk betere acceptatie van hun product en ervoeren minder drang om te roken gedurende de eerste 4 weken van hun stoppoging dan de deelnemers in de NRT-groep. Ook gaven zij hun toegewezen product een gunstigere beoordeling. Deelnemers aan e-sigaretten groep rapporteerden na 1 jaar significant minder hoesten en slijm dan deelnemers van de NRT-groep (controle op rookstatus). Dit ondersteunt eerdere rapporten die suggereren dat een ingrediënt in e-sigaretten (d.w.z. propyleenglycol) vapers kan beschermen tegen infecties in de lucht. Startpakketten voor e-sigaretten kosten veel minder dan NRT en dus, als SSS's ze bieden, zal hun gebruik waarschijnlijk de slagingspercentages verhogen en de kosten van SSS's verlagen.

Conclusies: In het kader van een multisessie behandeling voor rokers die hulp zochten, waren e-sigaretten aanzienlijk effectiever dan NRT. Uit een gedetailleerde economische analyse blijkt dat, omdat e-sigaretten lagere nationale gezondheidskosten met zich mee brengen dan NRT producten en een hoger stoppercentage genereert, het gebruik van e-sigaretten kosteneffectiever is. Als SSS's dus startpakketten voor e-sigaretten gaan leveren, zal dit zeer waarschijnlijk hun slagingspercentages verhogen en hun kosteneffectiviteit verbeteren.

Nog te onderzoeken: De effectiviteit van e-sigaretten met verschillende ondersteuningsniveaus zal uitwijzen of rokers moeten worden aangemoedigd om binnen ondersteunende diensten over te stappen op vapen of dat e-sigaretten kunnen worden aanbevolen met minder intensieve of zelfs helemaal géén ondersteuning.

FInanciering: Dit project werd gefinancierd door het National Institute for Health Research (NIHR) Health Technology Assessment-programma en zal volledig worden gepubliceerd in Health Technology Assessment; Vol. 23, No. 43. Zie de website van de NIHR Journals Library voor meer projectinformatie. De proef werd ondersteund door de Cancer Research UK Prevention Trials Unit (subsidie ​​A16893).

Any policy intervention that reduces smoking in the Netherlands has our full support. We regret however, that the Agreement fails to acknowledge the important role that products that do not involve combustion and inhalation of smoke can play in reducing the harms caused by smoking. Such products include forms of low nitrosamine smokeless tobacco such as snus, vaping technologies and pharmaceutical or pure nicotine products. From a health perspective, the major distinction between nicotine products is whether they are combustible or non-combustible. It is well known that it is the smoke, not the nicotine, which causes almost all of the smoking related diseases and non-combustible products have a clear role to play in reducing smoking prevalence to meet the ambitious objectives set out in the Agreement.

The public health opportunities for harm reduction are vast, and in the case of vaping (e-cigarettes) these have been well described by the Royal College of Physicians of London (RCP) in its thorough April 2016 report (2) and more recently by McNeil el al. (2018) in a report to Public Health England (3). For example, on the subject of relative risk, based on smoke and vapour toxicology the RCP stated:

"Although it is not possible to precisely quantify the long-term health risks associated with e-cigarettes, the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure". (5.5)

On the subject of smoking cessation, there is increasing evidence from Randomised Controlled Trials (RCT) that have been designed specifically to explore effects on tobacco smoking, that vaping products (e-cigarettes) can help smokers to stop smoking. A Cochrane review published in 2016 concluded that smokers using an e-cigarette were more likely to quit compared to those using a placebo at 6 months (4). More recently, a RCT of e-cigarettes versus Nicotine Replacement Therapy (NRT) alongside behavioural support in England, reported an almost two-fold increase in 12 month quit rates with e-cigarettes (5).

On the question of what the products are being used for, the RCP is clear they are alternatives to smoking and used primarily by smokers to reduce their health risks.

“…the available evidence to date indicates that e-cigarettes are being used almost exclusively as safer alternatives to smoked tobacco, by confirmed smokers who are trying to reduce harm to themselves or others from smoking, or to quit smoking completely. “

Similarly, in a recent review of findings from five large-scale surveys of 60,000 young people in the United Kingdom (6) although some experimentation was reported, regular use remained very low, ranging from 0.1 to 0.5%. Recent survey data from the UK suggests this pattern has not changed7. The report conclude that:

“…surveys across the UK show a consistent pattern: most e-cigarette experimentation does not turn into regular use, and levels of regular use in young people who have never smoked remain very low.”

As is the case across the globe, in the Netherlands there are many smokers that are unable or unwilling to quit, not least of all, the poorest and most disadvantaged in society who find smoking cessation the most difficult. This large group, including those suffering from mental illness, would benefit from switching to smoke-free products. In this regard it is critical that adult smokers can be informed about these innovative products and receive non-misleading information about their relative risk.

However subjecting e-cigarettes and other smoke-free products to the same restrictions as for combustible cigarettes can have unintended consequences and can favour the tobacco industry. For example, treating vaping the same as smoking in public places has no scientific basis but could discourage smokers from using a less risky product, causing harm to health by perpetuating smoking and rewarding the cigarette trade. Advertising display bans for e-cigarettes similarly favour the incumbent product (cigarettes) and form a barrier to the much less risky innovative new products. The RCP recognises the potential for unintended consequences and states that:

“However, if [a risk-averse, precautionary] approach also makes e-cigarettes less easily accessible, less palatable or acceptable, more expensive, less consumer friendly or pharmacologically less effective, or inhibits innovation and development of new and improved products, then it causes harm by perpetuating smoking.” (Section 12.10 page 187)

Whilst we welcome tighter restrictions on cigarette smoking, treating non-combustible products such as e-cigarettes in the same way, sends the wrong message that smoke-free products are as harmful as cigarettes. This will discourage smokers from switching, which leads to the unintended consequence that cigarette use is prolonged. Obviously this goes against the Agreement’s objective to eradicate smoking.

We respectfully request that the Lower House carefully assess the role that non-combustible products such as e-cigarettes can play in reducing tobacco smoking and recommend an exemption for e-cigarettes from the bans on display/advertisement and smoking in public places. We are more than willing to provide you with further information and our perspective on the international developments in the field of tobacco harm reduction and draw your attention to recent letter to the World Health Organisation (WHO) from 72 specialists in the field (8) which offers some guiding principles for consideration for the Framework Convention on Tobacco Control (FCTC). We would welcome the opportunity to contribute to a round-table in your Committee should you decide to organize such type of event.

We confirm that signatories report no conflicts with respect to FCTC Article 5.3 and no financial conflicts of interest with respect to tobacco or e-cigarette companies under the International Committee of Medical Journal Editors (UCJME) reporting standard.

Yours sincerely,

David B Abrams PhD. Professor Dept of Social and Behavioral Sciences NYU College of Global Public Health New York University. United States

Frank Baeyens,PhD Professor Faculty of Psychology and Educational Sciences KU Leuven Belgium

Clive Bates, MA, MSc Director, Counterfactual Consulting Former Director, Action on Smoking and Health UK London United Kingdom

Linda Bauld, BA PhD FHEA FRCPE Bruce and John Usher Chair in Public Health Usher Institute University of Edinburgh Deputy Director, UK Centre for Tobacco & Alcohol Studies Honorary Professor, University of Stirling United Kingdom

Ron Borland PhD, FASSA Nigel Gray Distinguished Fellow in Cancer Prevention, The Cancer Council Victoria, Melbourne Vic 3004
Australia

Thomas H. Brandon, Ph.D. Department Chair and Program Leader, Health Outcomes and Behavior Moffitt Distinguished Scholar Director, Tobacco Research & Intervention Program Moffitt Cancer Center Professor, University of South Florida Departments of Psychology and Oncologic Sciences

Pasquale Caponnetto Professor of Clinical and General Psychology Center of Excellence for the acceleration of HArm Reduction – CoEHAR University of Catania via S. Sofia 78, Catania, Italy

Sharon Cox, PhD Research Fellow Centre for Addictive Behaviours Research School of Applied Sciences London South Bank University United Kingdom

Lynne Dawkins, PhD
Associate Professor Centre for Addictive Behaviours Research
School of Applied Sciences London South Bank University
United Kingdom

Jean-François Etter, PhD Professor of Public Health Institute of Global Health Faculty of Medicine University of Geneva
Switzerland.

Konstantinos Farsalinos, MD, MPH Researcher Onassis Cardiac Surgery Center National School of Public Health University of Patras, Greece

Stuart Ferguson Associate Professor Division of Medicine, School of Medicine
College of Health and Medicine University of Tasmania Private Bag 34 Hobart 7001 Tasmania

William T. Godshall, MPH Executive Director Smokefree Pennsylvania 1926 Monongahela Avenue Pittsburgh, PA 15218 412-351-5880 United States

Peter Hajek, PhD Professor of Clinical Psychology Director, Tobacco Dependence Research Unit Wolfson Institute of Preventive Medicine, Queen Mary University of London United Kingdom

Jacques Le Houezec, PhD Independent consultant in Public Health & Tobacco dependence - Smoking Cessation Specialist Rennes, France. Honorary Clinical Associate Professor, UK Centre for Tobacco and Alcohol Studies, School of Medicine, University of Nottingham, UK.

Jason Hughes, PhD Professor and Head of School of Media, Communication and Sociology University of Leicester Leicester, LE1 7LA United Kingdom

Sarah Jackson, PhD CPsychol Senior Research Associate UCL Tobacco and Alcohol Research Group Department of Behavioural Science and Health University College London United Kingdom

Martin J Jarvis, DSc OBE Emeritus Professor of Health Psychology Department of Behavioural Science & Health University College London United Kingdom

Leon Kosmider, PhD, PharmD Research Assistant Professor Technical Director, Bioanalytical Shared Resource Laboratory School of Pharmacy Department of Pharmaceutics Virginia Commonwealth University Richmond United States

Lynn T. Kozlowski, PhD Professor of Community Health and Health Behavior Former Dean School of Public Health and Health Professions University at Buffalo, State University of New York New York United States

Christopher E. Lalonde, PhD
Professor of Psychology University of Victoria British Columbia Canada

Karl E Lund, PhD Senior Researcher Norwegian Institute of Public Health Oslo, Norway

Colin Paul Mendelsohn, MB BS (Hons) Conjoint Associate Professor School of Public Health and Community Medicine University of New South Wales Sydney Australia

Bernhard-Michael Mayer, PhD Professor of Pharmacology and Toxicology Institute of Pharmaceutical Sciences Karl-Franzens-Universität Graz Austria

Fares Mili, MD, CTTS Addictologyst & Pulmonologyst Chairman Tunisian Society of Tobacology and Addictive Behaviours (STTACA) Tunisia

Caitlin Notley, PhD Senior Lecturer in Mental Health Addictions Research Group Norwich Medical School University of East Anglia Norwich United Kingdom

Konstantinos Poulas, PhD Associate Professor
Department of Pharmacy University of Patras Head of the Institute NoSmoke.Team Patras Science Park Greece

Lars M. Ramström, PhD Principal Investigator Institute for Tobacco Studies Täby, Sweden

Louise Ross Clinical Consultant National Centre for Smoking Cessation Training
Dorchester United Kingdom

Lion Shahab, PhD Associate Professor Department of Behavioural Science and Health University College London United Kingdom

Andrzej Sobczak, PhD Head of Department of General and Inorganic Chemistry Medical University of Silesia Sosnoiwec, Jagiellonska 4, Poland

Roberto A Sussman, PhD Department of Gravitation and Field Theories Institute for Nuclear Research, National Autonomous University of Mexico, ICN-UNAM Representing Pro-Vapeo Mexico AC Mexico

David Sweanor, JD Chair of Advisory Board of the Center for Health Law, Policy and Ethics University of Ottawa Canada

Umberto Tirelli MD Professor Director, Cancer Center Clinica Mede Sacile Italy

Robert West, PhD Professor of Health Psychology and Director of Tobacco Studies Department of Behavioural Science and Health University College London United Kingdom

Alex Wodak AM, Emeritus Consultant, Alcohol and Drug Service, St Vincent's Hospital President, Australian Drug Law Reform Foundation Director, Australia21 Darlinghurst, NSW, 2010, Australia

References

1. National Prevention Agreement: https://www.rijksoverheid.nl/documenten/convenanten/2018/11/23/nationaal-preventieakkoord

2. Royal College of Physicians (London), Nicotine without smoke: tobacco harm reduction. 28 April 2016 https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0

3. McNeil, A., Brose, LS., Calder, R., Bauld, L. & Robson, D. (2018). Evidence review of e-cigarettes and heated tobacco products 2018. A report commissioned by Public Health England.
   https://www.gov.uk/government/publications/e-cigarettes-and-heated-tobacco-products-evidence-review

4. Hartmann-Boyce, J., McRobbie, H., Bullen, C., Begh, R., Stead, L.F. & Hajek, P. (2016). Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews, Issue 9, Art. No.: CD010216. https://www.cochrane.org/CD010216/TOBACCO_can-electronic-cigarettes-help-people-stop-smoking-and-are-they-safe-use-purpose

5. Hajek, P., Phillips, A., Przulj, D., Pesola, F., Myers Smith, K., Bisal, N., Li, J., Parrott, S., Sasieni, P., Dawkins, L., Ross, L., Goniewicz, M., Wu, Q. & McRobbie, H. (2019). A randomized trial of e-cigarettes versus nicotine-replacement therapy. New England Journal of Medicine, Jan 30. DOI: 10.1056/NEJMoal808779.
   https://www.nejm.org/doi/full/10.1056/NEJMoa1808779

6. Bauld, L ., MacKintosh, AM., Eastwood, B., Ford, A., Moore, G., Dockrell, M., Arnott, D., Cheeseman, H. & McNeill, A. (2017). Young people’s use of e-cigarettes across the United Kingdom: findings from five surveys 2015-2017. International Journal of Environmental Research and Public Health, 14 (9), 973. https://www.mdpi.com/1660-4601/14/9/973

7. McNeil, A., Brose, LS., Calder, R., Bauld, L. & Robson, D. (2019). Vaping In England: an evidence update February 2019. A report commissioned by Public Health England. London: Public Health England. https://www.gov.uk/government/publications/vaping-in-england-an-evidence-update-february-2019

8. Letter from seventy-two specialists in nicotine science, policy and practice.
   https://clivebates.com/documents/WHOCOP8LetterOctober2018.pdf